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Full text of "Tuberculous disease of bones and joints; its pathology, symptoms, and treatment"

CORNELL UNIVERSITY. 



THE 

Wltxmvv IDibrairg 

THE GIFT OF 

ROSWELL. P. FLOWER 

FOR THE USE OF 

THE N. Y. STATE VETERINARY COLLEGE. 

1897 



CORNELL UNIVERSITY LIBRARY 




3 1924 104 224 575 




The original of this book is in 
the Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://archive.org/details/cu31924104224575 



TUBERCULOUS DISEASE OF 
BONES AND JOINTS. 




NUNQUAM AI.IUD NATURA, ALIUD SAPIENTIA DIC1T. 



TUBERCULOUS DISEASE 



OF 



BONES AND JOINTS 



ITS PATHOLOGY, SYMPTOMS, AND 
TREATMENT. 




W. WATSON CHEYNE, M.B.Ed., F.R.S., F.R.C.S., 

PROFESSOR OF SURGERY IN KING'S COLLEGE J SURGEON TO KING'S COLLEGE HOSPITAL AND 
PADDINGTON GREEN CHILDREN'S HOSPITAL, LONDON. 



WITH SIXTY-THREE ILLUSTRATIONS. 



EDINBURGH AND LONDON: 

YOUNG J. PENTLAND. 
PHILADELPHIA : J. B. LIPPINCOTT COMPANY. 

1895. 



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EDINBURGH = PRINTEDFOSVOUKG j. PENTLAND, II TEVIOT PLACE AND 
38 WEST SMITHFIELD, LONDON, EX. 

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[A U rights reser?>ed. ] 



PREFACE. 



I have divided the matter of the following work into two 
parts — the first of which deals with the pathology and 
treatment of tuberculous disease of bones and joints in general, 
and the second with the symptoms and treatment, founded 
on the foregoing pathology, of the individual bones and joints 
in particular. The first part is based on my Astley Cooper 
Prize Essay, written in 1888, although some modifications 
have been made in it, and much has been omitted as being 
unsuitable for the present purpose. In preparing that Essay 
I went over the whole pathology of these diseases for myself, 
especially by the aid of complete thin sections of the affected 
parts, and was, in this way, able to get a very complete view 
of the sequence of events. I had originally hoped to be 
able to reproduce the beautiful photographs of these sections 
which were made for me at the time by Mr. Andrew Pringle, 
but I found that the expense of their proper reproduction 
was so great as to render such an attempt altogether out 
of the question. A good deal of this part has also been 
published in the form of lectures at the Eoyal College of 
Surgeons. The second part of the book will, I hope, be of 
use to those who are called on to treat these obstinate and 



vi PREFACE. 

very serious cases, and the treatment described is that which 
I have myself found best, and which is now generally 
employed by those who have paid special attention to these 
diseases. The delay in the appearance of this work, which 
is in part my Astley Cooper Prize Essay of 1889, and is 
published with the permission of the Governors of Guy's 
Hospital, has been due to my desire to assure myself, from 
sufficient experience, that the treatment I was recommending 
was founded on a sound pathological and practical basis. 



W. Watson Cheyne. 



75 Hakley St., W., 
May 1895. 



CONTENTS. 



CHAPTER I. 

definition op the term " tubercle " and 
"tubercular tissue." 

PAGE 

History — Histology of Tubercle — Epithelioid Cells — Essential Elements of 

Tubercle — Life History of Tubercle — Definition of Tuberculosis, . 1 

CHAPTER II. 

CHANGES IN THE SYNOVIAL MEMBRANE. 

Synovial Thickening — Mode of Spread — Types of Diffuse Synovial Dis- 
ease — Clinical Significance of the Changes — Localised Thickening — 
Acute Miliary Tuberculosis — Hydrops Tuberculosus, . . .19 

CHAPTER III. 

TUBERCULAR DEPOSITS IN BONE. 

Acute Miliary Tuberculosis — Soft Caseating Deposits — Mode of Extension 
— Sequestrum Formation — Tubercular Sequestra — Process of Seques- 
trum Formation — History of Tubercular Sequestra, . . .31 

CHAPTER IV. 

TUBERCULAR CHANGES IN ARTICULAR CARTILAGE AND THE 
SURFACE OP BONE. 

Destruction of Articular Cartilage — Pitting of the Cartilage — Destruction 
of Cartilage from Beneath — Caries — Sclerosis of Bone in Caries — 
Depth of the Carious Changes, ...... 46 

CHAPTER V. 

TUBERCULAR PERIOSTITIS AND TUBERCULAR OSTEOMYELITIS. 
Disease of the Vertebra — Tubercular Osteomyelitis — Strumous Dactylitis, 58 



viii CONTENTS. 

CHAPTER VI. 

RARER FORMS OF TUBERCULAR BONE DISEASE. 

PAGE 

Caries Sicca— Diffuse Condensation of Bone in connection with Tubercular 
Disease — Diffuse Softening of Bone and the Formation of "Red 
Marrow,'' ....-••■ «4 

CHAPTER VII. 

PATHOLOGY OF CHRONIC ABSCESS. , 

Commencement of Chronic Abscess — Chronic Suppuration in Joints — 

Etiology, ........ 70 

CHAPTER VIII. 

THE TUBERCULAR NATURE OF " STRUMOUS " JOINT DISEASES. 

Cases of Accidental Infection — Presence of Tubercles — Presence of 
Tubercle Bacilli — Association with Phthisis, &c. — Experiments with 
Tubercle Bacilli — Experiments on Goats — Experimental Disease of 
Joints, ......... 76 

CHAPTER IX. 

ON THE ACCESSORY FACTORS WHICH COME INTO PLAY IN THE PRO- 
DUCTION OF TUBERCULAR DISEASES OF BONES AND JOINTS. 

Causation of these Diseases — Points of Entrance of the Bacilli — Trans- 
mission from the Parents — Number of Bacilli — Relation to Injury — 
Frequency in Different Joints — Influence of Sepsis — Relation to Age 
— Relation to Sex — Relation to Food and Hygienic Conditions, . 93 

CHAPTER X. 

ON THE CURABILITY OF TUBERCULOSIS AND THE CAUSES WHICH 
INTERFERE WITH RECOVERY. 

Relation of the Bacilli to the Living Tissues — Retrogressive Changes — 
Spontaneous Cure — Recovery in Bone Disease — Risk of Infection — 
Question of Heredity — Influence of Climate — Relation to Food — 
Relation to other Diseases — Influence of Injury — Influence of Sepsis, . 122 

CHAPTER XI. 

TREATMENl\OF TUBERCULAR DISEASE OF BONES AND JOINTS. 

Methods which act on the Body — Prophylaxis — Climate — Exercise — Rest 

— Extension — Extension in Paraplegia, .... 136 



CONTENTS. ix 

CHAPTER XII. 

TREATMENT OF TUBERCULAR DISEASE OP BONES AND 

joints — continued. 

PAGE 

Methods which do not act directly on the Bacilli — Counter Irritation — 
Actual Cautery — Tubercular Peritonitis — Arthrotomy — Pressure — • 
Massage — Koch's Treatment — Benzoate of Soda — Local Injections, . 1 52 

CHAPTER XIII. 

TREATMENT OP TUBERCULAR DISEASE OP BONES AND 

joints — continued. 

Methods which act directly on the Tubercular Tissue — Local Injections — 

Expectant versus Operative Treatment — Tuberculosis after Operation, 165 

CHAPTER XIV. 

GENERAL PRINCIPLES OF TREATMENT. 

Choice of Operation — Influence of Chronic Suppuration — Treatment of 
Chronic Abscess — Influence of Sepsis — Treatment of Septic Sinuses — 
Arthrectomy — Partial Arthrectomy, . . . 173 

CHAPTER XV. 

ARTHRECTOMY, EXCISION, AND AMPUTATION IN JOINT DISEASE. 

Amputation — Complete Arthrectomy — Arthrectomy versus Excision, . 186 

CHAPTER XVI. 

DISEASE OP THE HIP JOINT. 

Pathology of Hip-Joint Disease— Stages of Hip- Joint Disease — Symptoms 
of the Eirst Stage — Diagnosis of the First Stage — Symptoms of the 
Second Stage — Diagnosis of Second Stage— Symptoms of the Third 
Stage — Pelvic Abscess — Symptoms of the Fourth Stage — Prognosis- 
Treatment of the First Stage— Thomas's Hip Splint— Extension- 
Actual Cautery— Question of Early Operation— Treatment of Second 
Stage — Apparatus during Second Stage — Operation during Second 
Stage— Objections to Excision— Treatment of Third Stage— Treat- 
ment of Abscesses— Operation of Excision— Treatment of the Fourth 
Stage, 195 



x CONTENTS. 

CHAPTER XVII. 

DISEASE OF THE KNEE JOINT. 

PAGE 

Pathology of Knee Joint Disease— Symptoms of Knee Joint Disease- 
Localised Synovia] Disease — Diffuse Primary Synovial Disease— 
Caries— Primary Bone Disease — Symptoms of Bone Deposits— Diag- 
nosis of Tubercular Disease of the Knee Joint— Treatment— Splints 
for Knee Joint Disease— Thomas's Knee Splint— Early Operation— 
Arthrectomy— Arthrectomy at a, later Stage— Excision — Treatment 
of Third Stage— Treatment of Septic Sinuses— Treatment of Bone 
Deposits, . . ....-• 248 

CHAPTER XVIII. 
DISEASE OP THE ANKLE, TARSUS, AND METATARSUS. 

Parts Affected — Disease of the Ankle Joint — Disease of the Tarsal Bones 
— Treatment of Ankle Joint Disease — Arthrectomy of Ankle — 
Amputation for Ankle Disease — Treatment of Tarsal Disease — 
Mikulicz-Wladimiroff Excision, ...... 286 

CHAPTER XIX. 

DISEASE OP THE SHOULDER JOINT. 
Pathology — Symptoms — Treatment — Excision of the Shoulder Joint, . 304 

CHAPTER XX. 

DISEASE OF THE ELBOW JOINT. 

Pathology — Symptoms — Treatment — Arthrectomy of the Elbow Joint — 

Excision of the Elbow Joint, . . . . .310 

CHAPTER XXI. 

DISEASE OF THE WRIST JOINT. 

Pathology — Symptoms of Wrist Joint Disease — Treatment — Excision 

versus Amputation, ..... . 316 

CHAPTER XXII. 

DISEASE OP SMALLER BONES. 

Disease of the Fingers and Toes — Disease of the Ribs, Clavicle, Scapula — 
Disease of the Sternum — Disease of the Skull — Disease of the Facial 
Bones, . . ...... 321 



CONTENTS. xi 

CHAPTER XXIII. 

DISEASE OF THE SPINAL COLUMN. 

PAGE 

Pathology of Spinal Disease — Symptoms of Spinal Disease — Seats of 
Spinal Abscess — Pressure on the Spinal Cord — Symptoms of Cervical, 
Dorsal, and Dorso-Lumbar Disease — Diagnosis — Treatment — Double 
Extension in Spinal Disease — Phelps's Box — Taylor's Brace — Double 
Extension in Paralysis — Treatment of Spinal Abscess — Sacro-Iliac- 
Disease, ......... 330 

Index, . .... . . 365 



LIST OF ILLUSTRATIONS. 



IG. PAGE 

1. Section of tubercular synovial membrane, .... 8 

2. Large giant cell from tubercle, with a ring of baciUi lying among the 

nuclei, ......... 12 

3. Section of a tubercle from tubercular synovial membrane, . . 15 

4. Transverse section of the ligamentum teres, from a case of tubercular 

disease of the hip, ....... 21 

5. Section showing under a higher power the character of the deeper or 

spreading edge of the tubercular area, . . 23 

6. Shows the free edge of the same section, ... 25 

7. Section of the innermost tissue not yet invaded by the tubercular 

growth, ........ 27 

8. Section of the external condyle of the femur from a case of disease of 

the knee joint, ....... 33 

9. Section of the head of the tibia, . . 35 

10. Section of a carpal bone, ...... 36 

11. Longitudinal section of the wrist joint from a case of tubercular 

disease, ....... 38 

12. Section of patella, showing commencing sequestrum formation, 39 

13. Section showing line of separation of a tubercular sequestrum, . 40 

14. Section of head of humerus, showing a tubercular sequestrum, . . 41 

1 5. Shows the extension of the soft tissue over the surface of the cartilage 

getting thinner and thinner, ...... 48 

16. Shows the articular cartilage undergoing destruction from the surface, 49 

17. Destruction of articular cartilage from the deeper surface, . . 51 

18. Section of head of tibia with a soft deposit under the cartilage, 54 

19. Section of the lower end of the femur, showing caries, . . .55 

20. Section of the body of a vertebra, showing caries of the surface, . 59 

21. Section of a phalanx, showing a tubercular sequestrum in the substance 

of the bone, ........ 61 

22. Section of the lower end of the ulna, showing tubercular osteomyelitis, 02 

23. Earliest commencement of a chronic abscess, . . . .71 

24. Section of a small chronic abscess hardly magnified, . . .72 

25. Magnified section of the wall of a chronic abscess, . . .73 

26. Section of the knee joint of » rabbit, after injection of a pure cultiva- 

tion of tubercle bacilli, . . . . . .85 

27. Section of the bones of the leg of a goat, two months after injection of 

tubercle bacilli into the nutrient artery of the tibia, . . .87 



LIST OF ILLUSTRATIONS. 



FIG. 

28. Section of knee joint of goat, after injection of a very small quantity of 

a pure cultivation of tubercle bacilli, . 

29. The same specimen as Figure 28, seen from the front, 

30. Wrist joint of goat, after injection of tubercle bacilli into the end of 

metacarpal bone, 

31. Soft deposit in the neck of the femur, 

32. Enlargement of the upper and back part of the acetabulum, 

33. Hip-joint disease on the right side, 

34. Same case (as Tig. 33) seen from behind, 

35. Hip-joint disease, showing the degree of flexion of the thigh, 

36. Hip-joint disease, showing the arching of the spine, 

37. Hip-joint disease, showing the degree of flexion, 

38. Hip-joint disease, showing extreme lordosis, 

39. Cross-legged deformity, the result of disease of both hip-joints, 

40. Single Thomas's splint applied, . 

41. Bonnet's wire cuirass for hip-joint disease, 

42. Synovial disease of the right knee joint, 

43. Old standing disease of the knee joint, . 

44. Arrangement for straightening a bent knee, 

45. Disease of the ankle joint, 

46. Result of excision of os ealcis, 

47. Disease of the right elbow joint, 

48. Disease of the carpus, ... 

49. Strumous dactylitis, ... . . 

50. Psoas abscess pointing at the upper and inner part of the left thigh, 

51. Position of the head in disease of the cervical spine, 

52. Disease in the mid-dorsal region with psoas abscess, 

53. Dorso-lumbar disease with iliac abscess, 

54. Phelps's box for spinal disease, . 

55. Child fixed in Phelps's box, 

56. Taylor's brace applied, . 

57. Taylor's brace, 

58. Apron for Taylor's brace, 

59. Taylor's chest piece, 

60. Cuirass for cervical or upper dorsal disease, 

61. Another form of neck support, . 

62. Taylor's brace, with head support, 

63. Ring support for head, 



90 

91 
197 
199 
202 
202 
203 
203 
211 
211 
221 
226 
230 
252 
255 
283 
290 
299 
311 
317 
322 
338 
341 
342 
343 
348 
350 
352 
353 
354 
355 
355 
356 
357 
358 



TUBERCULOUS DISEASE OF 
BONES AND JOINTS. 



SECTION I. 

PATHOLOGY, ETIOLOGY, AND TBEATMENT OF 
TUBEKCULAB DISEASE OF BONES AND 
JOINTS. 



DISEASES OF 
BONES AND JOINTS. 



CHAPTEE I. 

DEFINITION OF THE TEEMS "TUBERCLE" AND 
"TUBERCULAR TISSUE." 

The term " tubercle of bone " is a very old one, but it did not 
till comparatively recently bear the significance which is now 
assigned to it. At first it was applied to almost any nodule in 
bone, and thus included cancerous, syphilitic, tubercular, and 
other deposits. It was not till the time of Bayle and Laennec 
that more attention was paid to the miliary tubercle, and that 
the term acquired a more definite meaning, and was to some 
extent restricted to a definite specific disease of the same nature 
as tubercle in the lungs. The earlier works on tubercle of 
bones mainly dealt with Pott's disease of the vertebrae, and 
Delpech, in 1816, was the first to assert the close analogy of that 
disease with pulmonary phthisis, and he stated that tuberculosis 
was the only cause of that deformity which is called Pott's 
disease of the spine, and that therefore this affection should be 
termed tubercular disease of the vertebrae. The real starting 
point of the study of tubercle in bone was, however, Nichet's 
work on " Pott's Disease," published in 1835, and more especi- 
ally Nekton's work on " Tubercular Diseases of Bone," published 
in 1837. According to Nekton, tubercle of bone, like tubercle 
of the lungs, occurs under two forms to which he gives the 



4 "TUBERCLE" AND "TUBERCULAR TISSUE." 

names of "encysted tubercle" and "tubercular infiltration." 
In his opinion the encysted tubercle begins as a deposit of grey 
miliary tubercles in the cancellous spaces of bone leading to 
absorption of the intervening bony septa, and the formation of a 
space containing caseating tubercles surrounded by a more or 
less well-developed fibrous wall. In the other form there is at 
first a transparent greyish or reddish infiltration of the bony 
tissue followed by the formation of pus, and chiefly affecting the 
spongy bones. In Germany this subject was discussed by 
Meinel, Eokitansky, Virchow, and others, who all adopted some- 
what similar views, though with slight modifications. 

It is unnecessary to follow all the phases in the development 
of the views on tubercle of bone; they varied according to 
variations in opinion on the subject of tuberculosis generally. 
Nor need we dwell on the discussions as to how far these 
caseous deposits were, on the one hand, the results of the develop- 
ment of tubercle, or, on the other, only dried up and otherwise 
altered pus, and not the consequence but the forerunner, and, 
to some extent, the cause of tubercular development. Up till 
quite recently the diagnosis was made only by the naked eye, 
and thus it was only cases where distinct miliary tubercles or 
larger caseous masses were present that were included under 
this heading. Hence, on the one hand, it was by no means 
always possible to exclude gummata and other affections of bone 
from the group of tubercular affections ; and, on the other hand, 
it was only when distinct miliary tubercles or larger caseous 
masses were present that the disease was diagnosed. Conse- 
quently, till the histological side of the question was brought ' 
into prominence, the opinion of most surgeons was that, while 
tubercles were undoubtedly found in bones, they were compara- 
tively rarely present, and that there was no necessary relation 
between the well-known strumous diseases of bones and joints 
and tuberculosis; at any rate, no identity of origin. Even 
Volkmann, who has since done so much to establish the tuber- 
cular nature of scrofulous diseases of bones and joints, was at 



HISTOR Y. 5 

first (" Handbuch von Pitha Billroth, II.") inclined to think that 
in many cases it was only when the constitution had been 
lowered by the local joint affection that the patient became 
scrofulous or tubercular. Although, however, there were these 
difficulties in diagnosis, the idea seems to have entered the minds 
of several pathologists that many cases of so-called scrofulous 
diseases of joints, in which no tubercles were present to the 
naked eye, were probably of a tubercular nature, and that their 
pathology was closely allied to that of tubercular disease of the 
lungs. 

With the development of histological and pathological research, 
attention was directed to the histology of these affections, and a 
new era was opened up as regards their pathology. At first 
efforts were made to find some histological structure character- 
istic of tubercle, and as the result of the observations of 
Langhans on the almost constant presence of giant cells in 
miliary tubercles, of Schuppel on the epithelioid cells, and of 
Schiippel and E. Wagner on the presence of a fine reticulum, 
a definite structure was demonstrated and proved of great value 
in further histological work, although it must be admitted that 
at that time no single and definite histological characteristic of 
tubercle had been obtained. Koster, in 1869, was the first to 
thoroughly study these diseases of joints histologically, and to 
recognise fully their tubercular nature. He examined the 
synovial membrane in several cases of white swelling of joints, 
and found in all of them nodules of the size and character of 
miliary tubercles having one or more giant cells in their 
centre, lymphoid elements in their periphery, and a greater or 
less tendency to fatty degeneration, and he pointed out that so 
long as the conception of the term " miliary tubercle " was a 
histological one, so long must these miliary nodules in the 
swollen synovial membrane be looked on as true tubercles. 
Numerous investigations on this subject, and on the subject of 
tubercles in other parts of the body, followed in rapid succession 
till the discovery of the tubercle bacillus by Koch, and its 



6 "TUBERCLE" AND "TUBERCULAR TISSUE." 

demonstration in the synovial membrane and bones in these 
diseases placed the tubercular theory of their origin on a very 
sure basis. Among those who have become leaders in this 
matter may be mentioned Volkmann, Konig, and Lannelongue, 
who, taking into account the naked eye appearances, the 
microscopical characters, and the clinical features of scrofulous 
diseases of bones and joints, have worked out the subject so 
thoroughly that the view of the tubercular nature of these 
affections and of their intimate connection with tuberculosis 
elsewhere is now very generally accepted. 

A thorough knowledge of the morbid anatomy of tubercular 
diseases of bones and joints and of the mode of spread of the 
disease in the affected parts is very necessary at the present 
time, seeing that the methods of operative treatment, which 
have now come into vogue, aim mainly at thorough removal 
of the disease along with as small an amount of the unaffected 
tissues as possible, as distinguished from the older methods 
where certain rule of thumb operations were performed with 
but little reference to the extent or distribution of the affected 
tissue. I shall therefore, in the first instance, endeavour to 
show the distribution of the disease and its relation to 
surrounding parts as gathered from a study of complete thin 
sections of the affected bones and joints. I do not intend to 
go minutely into all the pathological points but only to discuss 
those matters' a knowledge of which is of essential importance 
for the satisfactory treatment of these affections. 

Before entering on the special pathology of tubercular 
diseases of bones and joints, I must say a few words as to the 
meaning of the terms " tubercle " and " tubercular tissue," and 
point out what are the essential elements in the tubercle, what 
its mode of origin, what its life history, and what the cause of 
its production. 

The general idea with regard to tubercular tissue is that it is 
a tissue containing tubercles, that is to say, containing more or 
less well defined nodules, and if no tubercles are found in a part 



HISTOLOGY OF TUBERCLE. 7 

it is concluded that that part is not the seat of tubercular 
disease. This view is, however, I am satisfied, too narrow, and 
its adoption has been one of the chief obstacles in the way of 
the early and general admission of the tubercular nature of 
these diseases of bones and joints. Tubercular tissue, as a 
matter of fact, presents two chief forms ; it may be a tissue 
containing well marked tubercles, or it may be, and frequently 
is in these joint diseases, a tissue which does not show any well 
defined tubercles, but which is nevertheless infiltrated with 
the essential tubercular elements, a condition which we 
may term shortly "tubercular infiltration." Both of these 
forms of tubercular tissue, viz., tubercles and tubercular 
infiltration, are found in tubercular diseases of bones and joints, 
and it is by no means uncommon to find at one part of a 
specimen a number of discrete tubercles and at another part 
a tubercular infiltration. 

The " tubercle " occurs in the form of a small microscopic 
nodule, circular or oval in shape, and usually a number of these 
nodules are aggregated together and have frequently coalesced 
with each other. In sections stained with various dyes, such 
as methylene blue, and examined under a low power, we 
generally see that the nodules consist of two parts, — a central 
portion, the larger, faintly stained, and an external part, much 
narrower and usually more deeply stained. The central portion 
is the essential part of the tubercle, and the external part is 
merely an adventitious wall. This wall may be either mainly 
cellular or mainly fibrous. Perhaps in most cases the wall is com- 
posed of a mass of small, round, deeply stained nuclei, the nuclei of 
leucocytes, which form a barrier around the tubercle (see Fig. 1). 
In other cases, there is a considerable amount of fibrous tissue 
in the wall ; in some instances, indeed, the wall may be almost 
entirely fibrous. As I shall presently point out, I believe 
that most of these tubercles with fibrous walls are formed in 
the interior of blood vessels, and that the fibrous wall is the 
remains of the vessel wall. In the central portion, the cells 



8 " TUBERCLE " AND " TUBERCULAR TLSSUE." 

are much larger than those outside ; their nuclei do not take on 
the stain so well, they are somewhat flattened, and from their 
resemblance to endothelium and some forms of epithelium, they 
are termed " epithelioid cells." Among these epithelioid cells 
we sometimes find a few leucocytes, recognised by their small, 
round, densely stained nuclei, but these cells are few in number 







Fig. 1. — Section of tubercular synovial membrane, showing a 
mass of tubercles under a low power. The majority of them 
contain a giant cell. The epithelioid cells which make up the main 
mass of the tubercle are indicated by the paler centre, as contrasted 
with the dark rim around, which is made up of a, dense mass of 
granulation cells. 

as compared with the epithelioid cells, and are frequently 
entirely absent. The nuclei of the epithelioid cells are large, 
oval or elongated, granular and more faintly stained than those 
of the external wall. These cells have usually only one nucleus, 
but not uncommonly two or more are present. 

The most striking thing in most tubercles is the large giant 
cells which are so frequently present. These cells are by no 



HISTOLOGY OF TUBERCLE. 9 

means constantly found, and are therefore not an essential part 
of the tubercle. They usually lie somewhat eccentrically, and 
consist of large masses of protoplasm of irregular shape, con- 
taining large numbers of nuclei presenting the same characters 
as those of the epithelioid cells. These nuclei may be distributed 
irregularly throughout the cell, but perhaps most commonly 
they are arranged in the form of a complete or incomplete 
circle around its margin, or are collected together in a mass 
at one end. 

As a rule, only one giant cell is present in each tubercle, but 
sometimes two are found, and we not uncommonly see that 
several of the epithelioid cells contain more than one nucleus. 

Processes frequently pass out from one or both ends of the 
giant cells ; in some cases, in the form of one or more broad 
protoplasmic bands, or of a number of finer threads. These 
processes, when present, may either join the protoplasm of the 
epithelioid cells or ramify among these cells, often extending 
as far as the wall. 

The presence of a reticulum, resembling that of lymphatic 
glands, and ramifying between the epithelioid cells, has been 
often described, but though I have for years directed special 
attention to this point, I have never been able to demonstrate 
to my satisfaction a reticulum in any way comparable to that 
of lymphatic glands, and I believe that what has been looked 
on as reticulum has been partly these processes of the giant 
cells, partly bands of fibrous tissue in connection with the wall 
of the tubercle, and partly, and probably chiefly, diffraction 
appearances due to bad illumination of the specimens. 

I would therefore describe a tubercle histologically as a 
microscopic nodule, generally round or oval in shape, composed 
of a central portion made up of epithelioid cells and sometimes 
giant cells, surrounded by a wall consisting of cells of inflam- 
matory origin, or of more completely formed fibrous tissue. 

As I have already said, tubercular tissue does not always 
present the nodular form ; indeed, in the case of bone and 



10 " TUBERCLE" AND " TUBERCULAR TISSUE." 

joint disease, it is very common to find, either along with or 
without the nodular form, a condition of what I have termed 
" tubercular infiltration." In this condition, which it is most 
important to recognise, the epithelioid cells are not collected in 
small masses, but either run through the tissue in broad tracts 
or are simply scattered irregularly among the other tissue 
elements. Giant cells are also frequently found in this peculiar 
mixed tissue. The tissue which is the seat of this infiltration 
presents two chief types, viz., granulation tissue or young fibrous 
tissue. 

In the cellular form, we find a mass of cells like those of 
granulation tissue, among which are numerous epithelioid and 
frequently giant cells. In Fig. 6 we see very well the mixture 
of cells and the absence of nodular form, while in other parts of 
the same section well defined tubercles were present. This is 
the kind of tissue which is generally found at those parts of 
the synovial membrane where caseation is going on, and it also 
precedes the formation of a chronic abscess. Where we find this 
tissue, we generally also find that the disease is extending rapidly. 
The fibrous form of tubercular infiltration is best seen in 
sclerosis of bone, in certain cases of caries, in caries sicca, in 
strumous dactylitis, &c. In this form we find more or less 
well-developed fibrous tissue infiltrated with cells chiefly of an 
epithelioid type, and having also a tendency, though less than in 
the preceding form, to break down and caseate. 

The question next arises whether there is any histological 
element which is characteristic of tubercle, and if so what it is. 
This is a question which has been much discussed, which has 
received various answers, and as to which there is by no means 
unanimity of opinion even at the present time. Small granules 
or irregular fragments of cells, giant cells, epithelioid cells, 
lymphoid cells, a fine reticulum, or several of these in combina- 
tion, have been at different times put forward as the essential 
and characteristic elements of the tubercle. In my opinion, the 
epithelioid cell is the characteristic element, and I think that 



HISTOLOGY OF TUBERCLE. 11 

when we find small collections of epithelioid cells, or larger 
tracts of them, and when they present the life history to be 
presently mentioned, we have to do with tubercular tissue. In 
the first place, the epithelioid cells are constantly present in 
tubercles and tubercular tissue. However uncertain the 
presence of giant cells, their processes, &c, the epithelioid cells, 
characterised by their size, appearance, and reaction with 
suitable staining reagents, are constantly found. In the second 
place, they are not only always present, but they also bear a 
constant relation to the tubercular virus — the tubercle bacillus. 
What first directed my special attention to these epithelioid 
cells, and what first convinced me that they were the charac- 
teristic histological elements of tubercle, was the peculiar 
distribution of the tubercle bacilli in the tubercular tissue. 
If we examine a tubercle stained to show tubercle bacilli, we 
find that the organisms are located either in or among the 
epithelioid cells, most usually, I think, in them, while they are 
not found at all among the inflammatory cells beyond the 
tubercular growth. In the epithelioid cells they are frequently 
closely applied to the nucleus. In cases where there is 
tubercular infiltration rather than definite tubercles we see the 
same thing ; the bacilli are chiefly found in connection with the 
epithelioid cells. So constant and marked is this relation that 
I have found it best when searching for tubercle bacilli in 
tissues where these organisms are few in number, to look with 
a low power for tracts of epithelioid cells, and then search for 
the bacilli among these cells. If one does not do this much 
time may be lost in examining portions of tissue in which these 
bacilli are not present, and when few in number the organisms 
may be entirely missed. If giant cells are present the bacilli 
are generally found in their interior in largest numbers, and 
when the bacilli are few in number they may be found only in 
giant cells. In giant cells with marginal nuclei the bacilli 
frequently form a ring around the margin lying among the 
nuclei (see Fig. 2). 



12 " TUBERCLE" AND " TUBERCULAR TLSSUE." 

The conclusion that the epithelioid cells are the essential 
histological elements of tubercle has also been arrived at by 
Baumgarten by the study of the elements in tubercle in which 
karyokinetic processes occur. Baumgarten has found that in 
tubercular tissue nuclear division occurs only in the epithelioid 
cells, and in the cells from which they are derived, and hence 
he comes to the conclusion that these epithelioid cells are the 
essential histological elements. 

Various authors have attempted to minimise the importance 



/ 



« 



*&'% 



* Ll 



\ 



\ 




Fig. 2. — Large giant cell from tubercle, with a ring of bacilli 
lying among the nuclei. 



of epithelioid and giant cells in the diagnosis of tubercle by 
asserting that these cells are found in other and non-tubercular 
tissues. No doubt cells of an epithelioid type do occur in 
various pathological tissues, for example, in guinmata, but there 
they are not so numerous, and they are never arranged in the 
characteristic nodules above described. Where nodules of the 
above character are present, and where their life history is that 



ESSENTIAL ELEMENTS OF TUBERCLE. 13 

to be presently mentioned, there caii be no question that we 
have to do with true tubercles, the great difficulty in diagnosis 
is between tubercular infiltration and some forms of granulation 
tissue, especially those where retrogressive changes are occurring. 
Here, however, a careful comparison shows marked differences 
between the two forms of tissue, more especially the large 
numbers of epithelioid cells in the tubercular form, and the 
diagnosis is made in the latter by the tendency to caseation— a 
point which I shall immediately allude to. It is often asserted 
that giant cells, like those of tubercle, are present in ordinary 
granulations.' For my own part I do not believe this. I have 
examined much granulation tissue, and have never seen giant 
cells at all resembling those found in tubercles, and I suspect 
that the observations in which they have been found have been 
made on strumous ulcers, or in sinuses after chronic abscesses, 
where tubercular giant cells are actually present. The ordinary 
myeloid cells of bone are much smaller than tubercular giant 
cells, and only have three or four nuclei, generally in the centre 
of the cell, and the only large cells in bone resembling tubercular 
giant cells are the osteoclasts, and the diagnosis is readily made 
by examination of the surrounding tissue. In any case, as I 
shall presently state, I should never depend for the diagnosis 
simply on the histological elements present, I should also take 
into consideration the life history of the new growth, more 
especially as shown under the microscope. 

The source of these epithelioid cells is in all probability 
manifold, and varies according to the situation of the tubercle ; 
they may be derived from epithelium, as in the lung, from the 
endothelium of blood or lymphatic vessels, from tissue cells, and 
very probably from the plasma cells on which so much stress 
has recently been laid by Ballance and Sherrington. In the 
tissues they are probably most often derived from the endo- 
thelium of blood vessels, though this is by no means an absolute 
rule. There has also been much dispute about the origin of the 
giant cells. They have been supposed to represent plugs in 



14 "TUBERCLE" AND "TUBERCULAR TISSUE." 

lymphatic vessels, with hypertrophy of the endothelium around 
the contents of the vessel forming the apparent protoplasm, and 
■ the ring of nuclei representing the nuclei of the original endo- 
thelial cells ; or a similar process in the blood vessels ; or hyper- 
trophied or coalesced endothelial cells, &c. My own opinion is 
that they are derived from the epithelioid cells either by hyper- 
trophy of individual cells or by coalescence of neighbouring 
cells - 

The discussion of the origin of these cells is, however, not 
essential, and I shall therefore not go into the matter, but as 
the vascular origin of tubercles is of great interest, I may say 
that I have, in several cases, been able to demonstrate the direct 
development of the endothelial cells of blood vessels into the 
epithelioid cells of tubercle, and have found all stages in 
the formation of tubercles in the interior of blood vessels. 
Kg. 3 shows another relation to the blood vessel, and in it 
we see the development of a tubercle in the substance of the 
internal coat of a blood vessel, the lumen of the vessel being 
still patent. 

The life history of the tubercle is an important element in 
its diagnosis, and there are two points in its life history which 
we must take into consideration — viz. (1) the fate of the indi- 
vidual tubercle, and (2) the tendency to the formation of fresh 
tubercles. 

Beginning in hypertrophy and new formation of cells, the 
nodule rapidly grows or the tubercular infiltration rapidly 
extends till it has attained, so to speak, its normal size or 
extent, and then retrogressive changes occur. We may roughly 
divide these changes into three great classes — viz. (1) simple 
atrophy and disappearance of the tubercle; (2) rapid caseation and 
breaking down, often leading to what is termed suppuration; 
and (3) slower degenerative changes generally ending in some 
degree of calcification. 

Simple atrophy of the cells of the tubercle, accompanied no 
doubt by more or less fatty degeneration or fibrous formation, 



DEGENERATIVE CHANGES. 



15 



probably frequently occurs in cases where healing takes place. 
I need not, however, go into a theoretical description of the 
process, but whatever it be it seems certain that during recovery 
from tubercular disease many tubercles disappear completely or 
undergo fibrous transformation, and that they do not all become 




Fig. 3. — Section of a tubercle from tubercular synovial membrane, 
showing its development in the substance of the internal coat of 
a blood vessel ; the lumen of the vessel being still patent. In the 
particular tissue from which this was taken (a case of synovial 
disease of the ankle joint), almost all the tubercles were apparently 
developed in this way. 

encapsuled or calcified, as seems to be the belief of many 
writers. 

Perhaps the most frequent change which occurs is caseation 
of the tubercle, and where the tubercles are very numerous or 
where tubercular infiltration is present the caseation may be 



16 " TUBERCLE" AND " TUBERCULAR TISSUE. 

rapid, and we have the process termed " chronic suppuration." 
The process of caseation, especially when it is extensive, as in 
joints, is generally preceded hy coalescence of tubercles and 
formation of the condition of tubercular infiltration. It 
frequently commences in the protoplasm of the epithelioid 
cells, but perhaps most often in the intercellular substance 
and in the processes of the giant cells. The protoplasm loses 
its homogeneous or finely granular appearance and becomes 
coarsely granular, while the nuclei break up into fragments 
which become distributed throughout the caseous material. 
The general appearance of the caseous material is seen in Fig. 6. 
The giant cell is one of the last structures to disappear, and we 
sometimes see that the caseous material extends up to and 
becomes continuous with the protoplasm of the cell, while the 
nuclei are still alive. 

Lastly, in some cases the tubercle neither atrophies nor 
caseates rapidly as above described, but the degenerative 
changes occur more slowly, and the degenerated material be- 
comes infiltrated with calcareous salts and can still be 
recognised even after many years. 

This is the life history of the individual tubercle, but another 
very important point in its life history is that it is an infective 
nodule, that is to say, that it does not remain single, but that 
once a tubercle develops, fresh ones spring up around the 
primary one. Indeed it is in this way that the tubercular 
process spreads, the new tubercles coalescing with the old and 
fresh ones appearing in the tissue around. And not only is the 
tubercle locally infective, it is also generally infective, a tuber- 
cular deposit in one part of the body being very apt to lead to 
tubercular growth elsewhere. The tubercular process is also 
infective from man to man, and from man to the lower animals 
and from the lower animals to man. A large number of cases 
of infection of wounds in man with tubercular material have 
now been published, and I need not therefore go into this 
matter. Nor need I go into the question of the infective agent 



DEFINITION OF TUBERCULOSIS. 17 

in tubercular material; that has been conclusively shown by 
Koch and others to be the tubercle bacillus. 

A further and very important point in the history of tubercles 
is that they are very irritating structures, and that the tissue in 
which they lie becomes the seat of simple inflammatory changes 
which extend far beyond the limits of the tubercular disease 
and produce very marked and destructive effects. 

To sum up we see that tuberculosis is an infective disease due 
to the growth in the tissues of a parasitic micro-organism — the 
tubercle bacillus. It is characterised by the production of a 
special form of tissue which may either present the form of 
nodules or of a more diffuse infiltration, the characteristic 
element of this tissue being the epithelioid cells. This tissue 
shows a great tendency to undergo a peculiar form of degen- 
eration termed caseation, and it also excites and keeps up a 
condition of inflammation in the tissues around. The primary 
nodule does not remain single but leads to fresh development 
of nodules both in the immediate vicinity and also frequently 
in distant parts. It is only by taking into consideration the 
histological characters of the tissue, the tendency to caseation, 
the presence of bacilli, the multiplicity of the nodules, &c, 
that we can come to a certain conclusion as to the tubercular 
nature of a disease. 

Of the various points which I have mentioned those which I 
consider most important are the presence of epithelioid cells, the 
multiplicity of the nodules or the extent of the epithelioid infil- 
tration, and the subsequent caseation. When we have numerous 
and evidently spreading tubercles or large tracts of tubercular 
infiltration, and where caseation is occurring, I know of nothing 
else which this can indicate but tubercular disease. Limited 
collections of epithelioid and giant cells may occur around 
parasites of various kinds, but there is no tendency to exten- 
sion of the process or to the formation of fresh epithelioid 
collections at a distance, while the constant tendency to 
multiplication is a characteristic of the tubercular process. 



18 "TUBERCLE" AND "TUBERCULAR TISSUE." 

I attach but little importance to the demonstration of tubercle 
bacilli as a means of diagnosis in these bone and joint diseases : 
the above mentioned histological characteristics are sufficient 
to enable the diagnosis to be made without the aid of the 
tubercle bacillus. 

We have thus arrived at a definite conception as to the histo- 
logical structure of tubercle, and we may conclude that when 
we find tissue with the characteristics described above, we have 
to do with tubercular disease. Now we find that the diseases 
in which this tissue is present are those which, up till recently, 
have been clinically known as strumous diseases, and therefore 
in speaking at the present time of surgical tuberculoses we mean 
those diseases which clinically would be diagnosed as strumous. 

There are many reasons why we must regard strumous 
diseases of bones and joints as tubercular, and being tubercular 
as due essentially to the development of the tubercle bacillus, 
and to these I shall refer again. I may here shortly summarise 
the facts as follows : — In the first place, I have just referred to 
cases in which wounds in man have become infected with the 
tubercular virus, with the result that the various affections, 
formerly called " strumous," and among them strumous diseases 
of bones and joints have developed. Further, in these strumous 
diseases the affected tissues show the presence of tubercles and 
tubercular tissue ; tubercle bacilli are constantly present, though 
often very difficult to find ; these affections are intimately related 
to phthisis and other tubercular affections occurring elsewhere ; 
the material derived from the diseased joints sets up tuberculosis 
in the lower animals in the same way as material from an 
undoubted tubercular source; and similar diseases can be 
induced in the lower animals by the introduction into bones 
and joints of tubercular material, and notably, as I have made 
out, of pure cultivations of tubercle bacilli. In describing the 
morbid anatomy of tubercular diseases of bones and joints, I 
therefore describe the morbid anatomy of those affections known 
up till recently as " strumous diseases." 



CHAPTER II. 

CHANGES IN THE SYNOVIAL MEMBRANE. 

In discussing the morbid anatomy of tubercular diseases of 
bones and joints, we shall study in the first instance the changes 
which occur in the synovial membrane, and in the second place 
those which occur in the bones. The disease may be primary 
or secondary in either of these tissues, and the character of the 
changes which take place varies accordingly. 

We may divide the changes which occur in the synovial 
membrane into four main groups : — (1) Various forms of diffuse 
thickening of the synovial membrane ; (2) limited thickening 
of the synovial membrane, more especially the formation of one 
or more fairly limited nodules ; (3) acute miliary tuberculosis 
of the synovial membrane ; and (4) a form where there is not 
much thickening of the capsule at first, but where there is 
hydrops or pyarthrosis, a condition described by Konig, and 
termed by him " tuberculous hydrops and tuberculous empyema 
of joints." 

1. The most important of these forms, and that which comes 
under our notice by far the most frequently, is the diffuse 
thickening of the synovial membrane. 

Here we find a great variety of conditions, and all sorts of 
transition stages, but if we examine the state of matters at an 
early period in the disease, we find that the changes may be 
divided into three great types. 

A frequent condition is that in which there is moderate 
thickening of the synovial membrane, which may be roughly 
divided into two parts — an internal layer, where the tissue is soft 
and at an early stage villous and later covered with caseating 



20 CHANGES IN THE SYNOVIAL MEMBRANE. 

material, and an external layer of firmer consistence and of a 
glistening character, without caseation. The soft tissue on the 
surface has a gelatinous appearance and can be frequently rubbed 
off with very slight pressure. In some cases, this soft material is 
not present over the whole surface of the thickened membrane, 
and in any case, it is usually distributed irregularly as regards 
its quantity, and is generally in largest amount at the reflection 
of the synovial membrane on to the bone or cartilage, or in the 
neighbourhood of any osseous deposit. "What I have just 
described may be looked on as, so to speak, the normal con- 
dition in this type of diffuse thickening ; but great differences 
exist as to the relative amount and distribution of the two 
kinds of material. Thus, in some cases, the soft tissue on 
the surface forms only a thin layer, the greater part of the 
thickening being composed of the firmer material, while in 
others, again, the reverse may be the case, and almost the whole 
of the thickened part may consist of the soft tissue. 

In a second type, we do not find this sub-division into two 
layers, the thickening being composed essentially of the firmer 
tissue, but this tissue is dotted over with transparent or opaque 
yellow spots of varying size, and sometimes shows distinct 
caseous patches or commencing chronic abscesses. 

In a third class of cases we have often very marked thicken- 
ing of the synovial membrane of the firm cedematous glistening 
character above described, but without the diffuse speckled 
appearance due to caseating patches, though it is not uncommon 
to find these collections here and there, especially over an 
osseous deposit which has reached the surface outside the 
joint at the point of reflection of the synovial membrane. In 
the first form, the joint generally contains serous or purulent 
fluid, while in the last two types fluid is usually absent. 

On studying the microscopical characters of complete sections 
of the synovial membrane, we find a similar diversity in the 
appearances, and we see the explanation of the naked eye 
characters. 



SYNOVIAL THICKENING. 



21 



The following drawings represent the condition of matters in 
the first type of synovial thickening which I have described. 
They are taken from a case of hip-joint disease in a girl, aged 
five, who was admitted with the following history :— Two and a 
half months before admission, she fell and struck her left hip. 
She had had no symptoms of hip-joint disease previously, but 
the parents thought that she had been losing flesh, and she had 



oKgpiiS^&i' jf '"Stow*. 

■■mm, , f-£x 



u* t 



m .1 



OR - wlfflil 




m 



Fig. 4. — Transverse section of the ligamentum teres from a case 
of tubercular disease of the hip, hardly magnified. The invasion of 
the ligament by tubercular tissue is well seen all round, and the 
tubercles can actually be made out at the deeper part. The ragged 
edge is where caseation is actively taking place. 

suffered from cough. Symptoms of hip-joint disease rapidly 
developed after the accident, and a few days before admission 
the head of the femur became dislocated forwards and upwards, 
and there was evidently fluid in the joint. I excised the 
joint, and clear fluid, containing white flocculent matter, was 



22 CHANGES IN THE SYNOVIAL MEMBRANE. 

evacuated, and a dense tubercular deposit was found at the lower 
part of the neck of the femur, which was evidently the starting 
point of the disease, and which had communicated with the 
joint. The synovial membrane was covered with villous masses, 
some of which were caseating on their free surface ; this villous 
material was soft and easily rubbed off. Fig. 4 represents a 
transverse section through the ligamentum teres, magnified 
about 3 diameters. At one part a small portion of the surface 
has become detached, but nevertheless we obtain an excellent 
idea of the state of matters. It will be seen that the section 
consists of two parts, — a central lighter portion, and an outer 
darker part. If we look at the outer portion we see that here 
and there at the edge it is breaking down, but at the innermost 
part it is composed of closely aggregated circles, with a light 
centre, dark outline, and often a small dark body in the interior 
of the circle. This peculiar material is seen to extend pretty 
completely round the margin, and to penetrate into the interior 
at various parts, especially between the bands of fibrous tissue. 
Fig. 5 shows the appearance under a higher power of the 
deeper part of this layer, and we see that the tissue at this 
part consists of densely packed tubercles, frequently with large 
giant cells, and surrounded by a ring of leucocytes. At the 
upper part of the photograph fresh tubercles are seen- forming 
in the more centrally placed tissue. Passing now to the free 
edge (shown in Fig. 6) we no longer see the individual tubercles, 
they have run together, and we have the condition which I 
have termed tubercular infiltration, and quite at the free edge 
this tissue is undergoing caseation. If, lastly, we study the 
central tissue (Fig. 7), we find that it is composed of very 
vascular delicate fibrous tissue, which is much swollen, and 
contains elongated cells, with processes like myxomatous 
cells, along with a few leucocytes. Except in the immediate 
neighbourhood of the tubercular masses there are no tubercles 
among this fibrous tissue. We may call this condition shortly 
" gelatinous infiltration." 



MODE OF SPREAD. 



23 



The sections of the synovial membrane showed exactly the 
same appearance, except that the tubercular layer was only at 
one side, the whole of the inner part of the synovial membrane 
being occupied by tubercular tissue, which was caseating at the 
free surface, while the outer part was composed of this swollen 
fibrous tissue. 

The sequence of events in these cases is plain. The tubercular 
virus has attacked the surface of the synovial membrane, and 




Fig. 5. — Section showing under a higher power the character of 
the deeper or spreading edge of the tubercular area. The numerous 
discrete tubercles are well seen. 

spread into its substance. In the ligamentum teres the tuber- 
cular growth is spreading in on all sides, where the tissue is not 
too dense. The oldest parts of the tubercular tissue, those 
next the cavity of the joint, are breaking down and under- 
going caseation, and the caseous material is being shed into the 
joint forming the flakes which were present in the fluid. 
Further, the fibrous tissue in the outer part of the synovial 



24 CHANGES IN THE SYNOVIAL MEMBRANE. 

membrane, or the interior of the ligamentum teres, has become 
much swollen, is more vascular than normal, and there has no 
doubt been new formation of tissue. 

These specimens represent very well the state of matters 
in the first form of synovial thickening which I described, 
where two layers can be made out, an inner, soft and often 
caseating, and consisting of tubercular tissue, and an outer, 
composed of swollen vascular fibrous tissue. This condition 
most frequently occurs, I think, as the result of infection from 
the interior of the joint, for example, from the bursting of an 
osseous deposit into it ; and associated with it, we generally 
find fluid containing pus cells and caseous material in the 
joint, due to the caseation of the surface of the tubercular 
growth. As time goes on the tubercular material gradually 
involves the whole of the synovial membrane, which is then 
no longer divisible into two layers, but consists entirely of soft 
caseating tissue with swollen, fatty, and fibrous tissue outside. 

In the second type of diffuse synovial thickening we find 
that the thickened synovial membrane is not distinctly 
divisible into two layers, but that it is somewhat tough with 
small or large transparent or yellow spots scattered through it. 
In this type the tubercular growth does not, in the first 
instance, form on the surface of the synovial membrane, but in 
its substance, though generally close to the surface, and the 
tubercles are generally scattered irregularly throughout the 
thickened tissue. As time goes on, however, the whole 
thickness of the synovial membrane becomes involved, and 
we may ultimately have a condition resembling the first type 
but differing in that the caseation most commonly occurs, in 
the first instance, beneath, not at the surface of the synovial 
membrane, seeing that the oldest tubercles are beneath the 
surface. Hence the characteristic appearances of yellow specks 
scattered through the substance of the thickened synovial 
membrane. In this type of synovial thickening we have 
generally to do with primary synovial disease. 



TYPES OF SYNOVIAL DISEASE. 



■2-1 



In the third type of diffuse synovial thickening the great 
mass of the thickened tissue is composed of the swollen fibrous 
tissue which is seen outside the tubercular growth in the first 
type, and the tubercles are few in number and in parts entirely 
absent. It is most important to bear in mind the existence of 
this type of disease, and the fact that there may be very 
marked thickening of the synovial membrane without any 








Fig. 6. — Shows the free edge of the same section. Here the 
tubercles have run together, and the condition of " tubercular in- 
filtration " has been produced. Caseation is going on at the edge, 
and some giant cells can still be seen. 

tubercles in it. This condition is either associated with 
primary disease of the synovial membrane, where the tubercular 
deposit is limited to some part of the thickened tissue, or 
perhaps it most often occurs in connection with osseous 
deposits which have not yet reached the surface or have done 
so at the point of reflection of the synovial membrane, but have 
been shut off from the joint cavity by the soft tissues over their 
point of exit. 



26 CHANGES IN THE SYNOVIAL MEMBRANE. 

In cases where we meet with this type of synovial thickening 
we may have to search a little before we find the tubercular 
area which, however, is present. Usually it will be found at 
some part where there is a greater amount of thickening, 
more especially at the reflection of the synovial membrane, or 
in some portion of the bone. 

To sum up we may say that the diffuse thickening of the 
synovial membrane may occur as a primary or secondary lesion. 
If it occurs primarily the deposit may and usually does com- 
mence at one part in the substance of the synovial membrane, 
and is not diffused over the whole membrane at once. At the 
point of commencement there is a deposit of tubercles, swelling 
of the surrounding tissue, and the tubercular growth soon 
spreads through the whole of the synovial membrane, being 
often, however, preceded by thickening of the membrane, due 
solely to swelling and gelatinous infiltration of the tissue. In 
these cases of primary disease of the synovial membrane the 
tubercular growth commences in its substance or even in the 
sub-synovial tissue, and these are often the cases in which 
we have the greatest thickening of the synovial capsule. 

Where the diffuse thickening occurs secondarily to deposits 
in the bone we may have one of two conditions according to 
the point where the deposit reaches the surface of the bone. 
If it communicates freely with the cavity of the joint there is 
rapid infection of the whole surface of the synovial membrane, 
tubercles form in the superficial layers, grow rapidly, and 
caseate at the free margin, while they also penetrate into 
its substance. At first the tissue outside becomes swollen 
from gelatinous infiltration, but subsequently this material is 
invaded and destroyed by the tubercular growth. In other 
cases the osseous deposit may reach the surface at the margin 
of the synovial membrane, which becomes thickened in the 
first instance, and shuts it off, for a time at any rate, from the 
joint cavity. This thickened patch is full of tubercles, and 
these rapidly spread in the substance of the synovial membrane 



CLINICAL SIGNIFICANCE OF THE CHANGES. 27 

or in the sub-synovial tissue, while the synovial membrane 
becomes swollen and gelatinous even before the tubercular 
deposit has reached it. 

At first sight one might be inclined to think that these 
details as to the various types of diffuse synovial thickening 
are only of pathological interest, and not of any special practical 
importance, but in reality their recognition is of great import- 
ance in treatment. Thus, suppose that we open a joint with 
the view of removing the tubercular disease and find that a 




Fig. 7. — Section of the innermost tissue not yet invaded by the 
tubercular growth. The tissue is swollen, cellular, with young 
vessels, in fact, in a state of subacute inflammation. This is the 
structure of the greater part of the tissue which constitutes the 
swelling of tubercular joints. 

primary osseous deposit has burst into the joint, we know from 
what I have pointed out that the tubercular disease will be 
confined, in the first instance, to the superficial layers of the 
synovial membrane, and that these layers are soft and easily 
removed, while the outer layers are tougher and composed only 
of inflamed and swollen fibrous tissue. It is evident, therefore, 
that in order to remove the tubercular disease, if we operate at 
an early period, we need not dissect away the whole of the 



28 CHANGES IN THE SYNOVIAL MEMBRANE. 

thickened tissues, destroying ligaments, &e., in our course, but 
that thorough, scraping of the surface will remove the whole of 
the disease, or at the most, the additional removal of a thin 
layer of the firmer tissue by knife or scissors will be sufficient. 
In this way we leave a strong joint, and may subsequently 
obtain some movement. 

Again, if we have to do with a case of primary synovial 
disease, we know that the tubercles are scattered irregularly 
throughout the thickened tissue, which is too tough to yield to 
the sharp spoon, and if we decide that it is necessary to remove 
the whole of the tubercular disease, we can only make sure of 
doing so by dissecting away the whole of the thickened tissues. 

In the third place, as illustrated by the third type, if an 
osseous deposit has reached the surface at the margin of the 
synovial membrane and caused thickening at that part, or if 
there is a localised primary deposit in the synovial membrane at 
one part, all that may be necessary at an early stage may be to 
remove the primary deposit and a good area of the synovial 
membrane around without touching the greater part of the 
synovial membrane, even although it may be somewhat 
thickened. 

2. Limited thickening of the synovial membrane. A com- 
paratively rare condition is that described by Konig, Eiedel, 
and others, where we have nodular, often polypoid, growths 
on the synovial membrane ; this generally occurs in the 
knee-joint. In most cases of synovial thickening the surface 
of the synovial membrane is not smooth, but shows irregular 
soft projections, but this is not the condition which is here 
referred to. In the cases to which I allude, we find one or more 
firm nodules projecting from some part of the capsule, generally 
in the pouch above the patella, and not unfrequently accom- 
panied by hydrarthrosis. At first there may be no general 
thickening of the synovial membrane, but if the disease is 
allowed to progress, the whole of the synovial membrane 



HYDROPS TUBERCULOSUS. 29 

ultimately becomes swollen and infiltrated with tubercles. 
Eiedel describes the characters of these cases as follows : — the 
synovial membrane is reddened, often thickened, and shows one 
or more firm prominences on the surface ; the joint frequently 
contains fluid and rice-like bodies ; the nodules contain numer- 
ous tubercles, frequently closely packed together. 

I have only seen one or two instances of this kind, and have only 
had the opportunity of examining one case. It was that of a 
lady who had suffered from troublesome synovitis of the knee- 
joint for some months. On the inner side of the joint a nodule 
was felt, which seemed like an attached loose cartilage. On 
cutting down, this was found to be a polypoid thickening of the 
synovial membrane, and was removed. On making sections of 
the mass, it proved to be tubercular. The patient remains 
well. 

3. Acute miliary tuberculosis of the synovial membrane. 
Konig describes a form of tuberculosis of the synovial mem- 
brane in which miliary tubercles are found in the sub-synovial 
tissue, and in which the synovial membrane is not at all altered ; 
there are no symptoms of disease. This condition occurs in 
acute general tuberculosis and is only of anatomical interest. 
I have in one case of acute tuberculosis examined the synovial 
membrane of the knee and hip-joints, but failed to find any 
tubercles. 

4. We have also to consider the condition of the synovial 
membrane in " Hydrops tuberculosus " and " Empyema tuber- 
culosum," described more especially by Konig and Volkmann. 
A certain amount of hydrops is not uncommon in connection 
with general thickening of the synovial membrane, and more 
especially with the pendulous growths just described, but the 
condition to which I refer here is that in which a joint affected 
with tubercular disease contains fluid, but where there is 
no marked thickening of the synovial membrane at first 



30 CHANGES IN THE SYNOVIAL MEMBRANE. 

although the disease is primarily synovial. This is, as a rule, 
only a temporary condition, and as time goes on the synovial 
membrane becomes swollen, the swelling generally commencing 
at the point of reflection of the synovial membrane on the 
bone, and ultimately the joint assumes the ordinary appearance 
of a tubercular joint. These cases are usually diagnosed in the 
first instance as simple hydrops, and it is not, as a rule, till the 
thickening of the synovial membrane has occurred that their 
true nature can be recognised, or that operative interference 
seems to be called for. Konig has examined these, cases at an 
early stage and states that there is a formation of a thin layer 
of tubercles on the surface of the synovial membrane, along 
with a slight amount of chronic inflammation. 

The " empyema tuberculosum " is a similar condition where, 
however, there is caseous pus in the joint cavity also without 
any marked thickening of the synovial membrane in the first 
instance. The typical cases of this kind are primarily synovial 
affections, occur especially in old people, and are particularly 
intractable. A very similar condition may, however, be found 
in some cases soon after an osseous deposit has opened into a 
joint. The appearance of the synovial membrane is very 
similar to that in the previous condition. 



CHAPTEK III. 

TUBERCULAR DEPOSITS IN BONE. 

The changes which occur in bone as the result of tubercular 
deposit in them, are very various, and to some extent merge 
into one another. The following are, however, the chief forms: — 
(1) Miliary tuberculosis of bone ; (2) soft caseating deposits in 
bone ; (3) tubercular deposits with sclerosis of bone and 
necrosis ; (4) superficial tubercular disease of the articular 
surfaces of bone, in connection with which we have to study 
the changes in the articular cartilage' — this form is always 
secondary to deposits in bone and to disease of the synovial 
membrane — (5) the condition termed " caries sicca " ; (6) diffuse 
condensation of bone, in connection with tubercular disease ; 
(7) diffuse softening of bone and formation of " red marrow ; " 
and (8) tubercular periostitis and tubercular osteomyelitis of 
the short bones, one form of which is " spina ventosa." In 
connection with these tubercular affections of bone we must 
also study the inflammatory processes which accompany them, 
and which play a most important part in the destructive 
changes. 

1. Miliary Tuberculosis of Bone. 

Miliary tuberculosis seldom occurs in bone, except in 
cases of acute general tuberculosis. It is true that we not 
uncommonly find miliary tubercles in bone in the vicinity of a 
large tubercular deposit, but I here refer to diffuse miliary 
tuberculosis apart from any large deposit. The appearance of 
the tubercles and the changes associated with them are the 
same as in other organs ; but as a rule the number of tubercles 



.32 ' TUBERCULAR DEPOSITS IN BONE. 

is not so great, and they are not uncommonly most numerous 
towards the extremities of the bone. For a long time the occur- 
rence of miliary tuberculosis in bone was entirely denied by 
some authors, but instances of this kind have been published 
from time to time, and Lazarus has recorded five cases of acute 
general tuberculosis, in which the bones were examined with 
positive results. In his cases, however, the tubercles were 
not present in all bones, or in all parts of the same bone. 
This form being only part of a fatal general disease is, however, 
of very little practical importance. 

Apart from acute general tuberculosis, or large deposits in 
bone, miliary tuberculosis of individual bones has been described. 
It is not uncommon to find tubercles, or what look to the 
naked eye like tubercles, in the sternum, ribs, and even the 
vertebrae in post-mortem examinations of cases of phthisis, and 
that although there is no general tuberculosis. 

2. Soft Caseating Tubekculak Deposits in Bone. 

Soft and frequently caseous tubercular deposits in bone are 
by no means uncommon as the primary condition in tubercular 
joint disease. These deposits vary much in size and situation, 
but they are as a rule small, and situated in the ends of the 
bones, usually close to the articular cartilage or the surface of 
the bone. They also vary in number, but in my experience 
they are most usually single, though in some cases there may 
be deposits in more than one of the bones entering into the 
formation of the joint, or in more than one part of the same 
bone. 

In this specimen (Fig. 8) we have an excellent example of one 
of these soft caseating deposits in bone. This is a section of the 
external condyle of the left femur of a child aged five. Two 
years before admission an abscess formed on the outer side of 
the left knee-joint, and burst, leaving a sinus ; the synovial 
membrane became much thickened, the knee flexed, and fresh 



SOFT DEPOSITS. 



33 



abscesses formed. The condition of the joint as seen at the 
operation was that the synovial membrane was much thickened, 
the articular cartilage of the patella was destroyed, the internal 
tuberosity of the tibia was much eroded, and there was a soft 



— fc. 




Fig. 8. — Section of the external condyle of the femur, from a case 
of disease of the knee-joint. Above is the articular cartilage, below 
the epiphysial cartilage, and between them, on the left hand, is a, 
soft tubercular deposit. (See Text for description.) 



caseous deposit in the external condyle of the femur, which 

communicated with the exterior, and to which the sinuses led. 

On examining this deposit we see that it is more or less 
3 



34 TUBERCULAR DEPOSITS IN BONE. 

circular in shape, and entirely composed of soft tissue, the 
osseous trabecules having completely disappeared. Towards the 
central part of the deposit caseation is occurring, around this 
there is a condition of tubercular infiltration, and elsewhere a 
number of tubercles. Immediately around the deposit the 
trabeculse of the bone are seen to be considerably thickened, 
and more numerous than at some distance from this spot. In 
the cancelli around the tubercular mass the normal fatty tissue 
has disappeared, and its place is taken by a swollen, somewhat 
fibrous, vascular material, not unlike that seen in gelatinous 
infiltration of the synovial membrane. Further away from the 
deposit the tissue in the cancellous spaces, presents a fairly 
normal appearance. Towards the left hand side we see that 
the deposit has destroyed the surface of the bone, and made its 
way outwards, leading to abscess formation over it. 

In Fig. 9 we have a caseous deposit immediately beneath 
the articular cartilage of the tibia, close to the spine. Here we 
have a similar appearance to that seen in the last specimen — 
viz., a central mass of caseous material without any bony 
spicule in it, surrounded by soft granulation tissue containing 
tubercles. Surrounding the soft deposit there are a few 
thickened trabeculse, as in the previous example, while further 
away the epiphysis is infiltrated with inflammatory cells, and 
the osseous trabeculse are thin and few in number ; in fact, the 
whole epiphysis is in a state of rarefying osteitis. At one part 
the deposit has burst through the cartilage, and opened into 
the joint. On each side of this point some fragments of carti- 
lage are still present on the surface of the bone, but further 
away the articular surface is destitute of cartilage and carious. 

As in the above specimens, these deposits generally undergo 
caseation in the centre, but in some instances this may not 
occur for a long time, and sometimes we find a mass of firmer 
fibrous tissue containing only a few tubercles scattered through 
it. In these deposits the osseous trabecular have usually been 
completely absorbed, though in some cases fragments of bone 



SOFT CASEATING DEPOSITS. 



35 



may still be seen. Immediately outside the tubercular growth 
it is not uncommon to find that the osseous trabecules are 
thicker than normal, but this condition does not extend to any 
great distance beyond the deposit, and, indeed, is not always 
present. Generally, also, we find that a few of the cancellous 
spaces around the deposit, more especially those in relation 
with the thickened trabeculae, are almost entirely devoid of 
fat cells, and contain a peculiar swollen semi-fibrous material, 
not unlike that found in the thickened synovial membrane in 



#^K 



f:i 



v w¥ 



m 



SgHIBsp 



mm 



mih 



WflMffi'mt 



m&. 






Fig. 9. — Section of the head of the tibia, showing remains of 
articular cartilage above, and a portion of the epiphysial cartilage 
below. On the right hand side the surface of the bone is carious. 
A soft tubercular deposit is present beneath the remains of the 
articular cartilage, which was perforated at one part. (See Text.) 

the neighbourhood of tubercular growth. Further away from 
these soft deposits we usually find a condition of rarefying 
osteitis. It is noteworthy, however, that here, as in caries, 
the rarefying osteitis is most marked at some distance from the 
deposit, the intervening tissue being less affected, and this 
rarefying osteitis often occurs in patches. Not uncommonly we 
find new osseous formation from the periosteum outside these 



36 



TUBERCULAR DEPOSITS IN BONE. 



deposits, but this is perhaps not so frequent as in the next 
form of tubercular bone disease. 

The process probably progresses somewhat in this way. The 
tubercular virus is deposited at some part of the bone, and 
tubercles form, the tubercles causing irritation, and the forma- 
tion of a young granulation tissue around them, which attacks 
the trabeculse of the bone, and leads to their absorption. The 






^^^^^^ 




Fig. 10. — Section of a carpal bone, commencement of a tubercular 
deposit in the superficial cancelli, destruction of the lamellse of the 
bone, &c. (See Text.) 

condition is illustrated in the accompanying drawing (Fig. 10) 
where we see the formation of tubercular tissue in neighbour- 
ing cancelli, and the lacunar absorption of the bone by the 
granulation tissue around the tubercular mass. The tubercles 
multiply, this granulation tissue extends, and absorption of the 
trabecule progresses, while caseation occurs at the oldest part of 



MODE OF EXTENSION. 37 

the growth. Further away from the tubercular mass, the irri- 
tation is less, and a small amount of young swollen fibrous tissue 
is formed, accompanied by sclerosis of the trabecule. This 
fibrous material is again invaded by the tubercular growth and 
the granulation tissue, and the thickened trabecule are again 
absorbed, and so the process goes on extending, aided, no doubt, 
by the rarefying osteitis which is occurring in the neighbour- 
hood, till ultimately the surface of the bone is reached. In 
some cases the tubercular growth is more rapid, and time is not 
afforded for total destruction of the trabecule before caseation 
is complete, and hence we find in these cases portions of osseous 
trabeculse in the midst of the caseous material, and the sclerosis 
of the surrounding bone may be absent. 

The further history of the case is as follows: — While the tuber- 
cular deposit is still enclosed in the interior of the bone, there 
may be only slight clinical evidence of its presence, but once it 
reaches the surface, various phenomena occur differing according 
to the point where the deposit has opened. If the deposit opens 
through the articular cartilage, and communicates directly with 
the joint, the infective material is distributed over the whole 
surface of the synovial membrane almost at the same time, and 
the first type of synovial disease rapidly develops, soon 
followed in most cases by the occurrence of caseous pus in the 
joint. In another set of cases the deposit reaches the surface 
at the point where the synovial membrane is reflected on to the 
bone, and is thus shut off for a time, at least, from the joint 
cavity. In this instance thickening of the synovial membrane, 
usually of the third type occurs, being most marked, especially 
at first, over the osseous deposit, but gradually extending and 
involving the whole of the synovial membrane. In a third set 
of cases, the deposit reaches the surface of the bone quite outside 
the synovial membrane, and then a chronic abscess usually 
forms over it, and the joint itself may never become affected. 

The sequence of events when the osseous deposit bursts into 
the joint cavity, is well shown in Fig. 11. This is a complete 



38 



TUBERCULAR DEPOSITS IN BONE. 



longitudinal section through the lower end of the radius, the 
carpus and the proximal end of the second metacarpal bone. 
At the posterior part of 
the carpal end of the meta- 
carpal bone (at the lower 
part of the figure), there is 
a caseous deposit which has 
opened into the carpo- 
metacarpal articulation. In 
this articulation the car- 
tilage is almost entirely 
destroyed, and the synovial 
membrane is thickened and 
villous ; the disease has 
spread to the articulation 
between the two carpal 
bones, which is filled up 
with fibrous tissue contain- 
ing tubercular tissue, and 
here also the cartilage has 
been almost entirely de- 
stroyed. The radio-carpal 
articulation is not nearly so 
much affected, but thicken- 
ing of the synovial mem- 
brane is occurring, and this 
thickened tissue is creeping 
over the surface of the car- 
tilage in the manner which 
I shall describe when I 
come to speak of the mode 
of destruction of cartilage. 
"We also see sections of 
sinuses in the soft parts, with caseating walls, and leading 
to the joints. 




Fig. 11. — Longitudinal section of the 
wrist joint from a case of tubercular dis- 
ease. At the lower part is the remains 
of a metacarpal bone towards the dorsum 
(right hand side), of which a deposit has 
formed in the bone, which has burst into 
the joint, and set up the disease. As we 
pass upwards we see two carpal bones and 
the radius. (See Text.) 



SEQUESTRUM FORMATION. 39 

3. Tubercular Deposits, with Sclerosis of Bone 
and Necrosis. 

In marked contrast to the foregoing processes are those in 
which there is sclerosis of bone and formation of sequestra. 
This process is very common in tubercular diseases of bone, 
varying much, however, in extent and result in different 
cases. 

The early stage of the process is well seen in Fig. 12, which 




Fig. 12. — Section of patella, showing commencing sequestrum 
formation at the lower and right hand part. (See Text.) 

represents a section of the patella from a case of disease of the 
knee-joint in a female aged sixteen. There was much swelling 
of the knee, and an abscess on the outer side of the patella ; the 
disease had commenced spontaneously. The specimen is an 
excellent example of this form of tubercular disease, and shows 
all the stages in the formation and separation of tubercular 
sequestra. In the photograph the trabecules of the bone 



40 TUBERCULAR DEPOSITS IN BONE. 

which elsewhere are black, come out light in the necrotic 
area. Bearing this in mind, we see that the trabecule in 
the necrotic area are very much thicker than in the healthy 
part, showing that a formative process has preceded the 
necrosis. Around the deposit rarefying osteitis is occurring, 
and the trabeculse are becoming destroyed, though this destruc- 
tion is only complete in a few places : the tissue at these parts 




Fig. 13. — Section showing line of separation of a tubercular seques- 
trum {see Fig. 12). The destruction of the trabeculse by granulation 
tissue and the formation of a tubercle in this tissue is well seen. 

contains numerous tubercles. In other parts at the margin, 
the cancelli contain vascular fibrous tissue, and the trabecule 
are becoming thickened. Nearer the centre tubercles appear 
in these cancelli, and the thickened trabecule are again 
becoming eroded, and at the centre the contents of the can- 
cellous spaces are caseous material, and the erosion of the 
trabeculse has come to a standstill. 

Fig. 13 represents the line of separation, and shows the 



TUBERCULAR SEQUESTRA. 41 

destruction of the trabeculse and the presence of tubercles in 
the soft tissue between the dead and the living. 

These sequestra vary in density very greatly, being in some 
cases only slightly denser or even less dense than normal can- 
cellous bone, while in other cases the trabeculse are extremely 
thickened, and the mass resembles the outer shell of a bone 




Fig. 14. — Section of head of humerus, showing a tubercular 
sequestrum completely separated but still in situ lying in a cavity 
in the bone, the wall of the cavity being composed of soft tissue. 
At the upper part the bone has in parts completely disappeared, and 
this soft tissue reaches the joint. (From a case excised by Sir 
William Fergusson many years ago.) 

rather than cancellous tissue. Further, the sequestrum does 
not always show the same density throughout. In the patella, 
from which the preceding figures have been taken, we have 
an example of the intermediate or what one may term the 



42 TUBERCULAR DEPOSITS IN BONE. 

normal density and character of one of these sequestra (see also 
Fig. 14). 

These tubercular sequestra are usually larger than the soft 
tubercular deposits, but they vary much in size and shape. 
They are generally quadrilateral or irregular in form, but they 
are sometimes wedge shaped, the base of the wedge being 
directed towards the cavity of the joint. In the freshly cut 
bone they present a dense yellow appearance, and it is very 
characteristic of the sequestra that they are usually incom- 
pletely separated. In some cases, the articular cartilage over 
them is destroyed, and they project into the joint cavity, and, 
if the joint has still been used, the surface of the sequestrum 
may be eburnated. As I have previously said, they vary in 
density from that of the hardest bone to a friable consistence, 
but most commonly they are denser thaii the normal cancellous 
bone. In most joints, they occur close to the articular ends 
of the bones, and frequently immediately under the cartilage ; 
in other cases, more especially in the upper end of the femur, 
they are found just beyond the epiphysial cartilage, or in the 
substance of the neck of the bone. 

When we study these sequestra under the microscope, we 
find that they are usually composed of much thickened osseous 
trabecule, and also of trabecular of new formation. The density 
of the newly formed bone varies in different cases, and this 
variation apparently depends on the rapidity and extent of the 
process. The meshes of the osseous network in these sequestra 
are filled with fibrous or granulation tissue frequently contain- 
ing tubercles, or more usually with caseous material ; where the 
sequestrum is very dense the amount of soft material in the 
meshes of the bone is naturally very small. Frequently, how- 
ever, even in very dense sequestra, many of the trabeculse have 
been a good deal broken up in places by the tubercular growth 
before caseation is complete, and thus are in a crumbling con- 
dition ; and usually, though many of the trabecular are much 
thickened, parts of the mass may break down readily under the 



PROCESS OF SEQUESTRUM FORMATION. 43 

finger. Surrounding the sequestrum we find a layer of soft and 
often fibrous tissue, generally containing tubercles or tubercular 
infiltration, which is leading in parts to destruction of the 
trabecular connecting the dead and living parts. 

The process of sequestrum formation in tubercular disease is 
probably shortly the following: — As the result of the deposit 
of tubercles in a certain part of the bone, there is inflammatory 
reaction in the neighbourhood, and ultimately the formation of 
young vascular fibrous tissue in a considerable number of the 
cancelli of the bone. In these cancelli thickening and new 
formation of osseous trabeculae go on, and this process con- 
tinues to extend at the edge. While this fibrous formation 
and sclerosis of the bone are going on, the tubercular growth is 
also extending, and, accompanying it, there is reabsorption of 
the newly formed bone. Caseation of this tubercular growth 
occurs, and then the absorption of the bone ceases, and thus we 
come to have a central patch of sclerosed bone with caseous 
material in the cancelli, surrounded by very vascular fibrous 
tissue and denser bone. By-and-bye the process ceases to 
extend with the same rapidity, and then absorption of the 
connecting trabecular of bone, and ultimately complete detach- 
ment of the sequestrum may take place. The thickness of the 
osseous trabecular in the necrosed fragment depends on the 
rapidity with which caseation of the tubercular deposit has 
occurred, and also on the course taken by that deposit. If 
caseation has only occurred slowly, there may be considerable, 
thinning and breaking up of the previously sclerosed trabeculse, 
while if it has occurred rapidly the thickness of the new bone 
is not much diminished. The tubercular growth may not, 
however, invade the whole of the sclerosed bone, and where it 
does not extend the sclerosis goes on and very dense bone is 
formed, this bone being ultimately cut off from the surrounding 
parts, and composing part or even the whole of the sequestrum. 
In some cases the tubercular growth follows a circular or 
triangular course around bone which has been invaded by it, 



44 TUBERCULAR DEPOSITS IN BONE. 

bone which has become much sclerosed but not invaded, and 
bone which has not been much affected. We thus see that in 
the formation of these sequestra we have two processes going 
hand in hand, viz., growth of vascular fibrous tissue with 
sclerosis of bone, and growth of tubercular tissue with rare- 
faction of bone; and the character of the sequestrum varies 
according to which of these processes is in excess, according to 
the rapidity with which the tubercular tissue extends or caseates, 
and according to the course taken by the tubercular growth. 
Formation of vascular fibrous tissue, with sclerosis of bone, is 
not uncommon in tubercular diseases of bones, but this sclerosis 
may go on to a great extent without ending in death. What 
determines the formation of a sequestrum is the invasion or 
encircling of this sclerosed tissue by the tubercular growth. 

Various views have been put forward at different times as to 
the nature of these sequestra. Some authors have supposed 
that they are composed mainly or entirely of fibrous tissue, 
while others have held that their density is due to the deposit 
of calcareous salts. Without doubt the caseous material in the 
cancelli in these sequestra is very apt to become infiltrated with 
calcareous salts, and when this is the case the weight and 
apparent density of the sequestra are much increased, but, as I 
have shown, this is not at all the essence of the process. The 
view, however, which has been most generally accepted is that 
advocated by Konig, viz., that these sequestra arise as the 
result of embolism, and that the vessel being blocked by 
tubercular material, the portion of bone supplied by it dies. 
Konig lays especial stress on the wedge shape and position of 
these sequestra as evidence of the accuracy of his opinion, and 
while he has not failed to observe that the osseous trabeculte in 
the sequestra are thicker than in the surrounding bone, he 
concludes that this is only an apparent sclerosis due to rare- 
faction of the surrounding bone. There can, however, be no 
question that the portion of bone which has died has previously 
been the seat of active growth, a fact quite irreconcilable with 



HISTORY OF TUBERCULAR SEQUESTRA. 45 

the embolic theory, and we see similar evidences of active growth 
in the bone around the deposit. This being the case, it is 
quite clear that whatever influence the distribution of the 
vessels may exert on the direction of spread of the tubercular 
tissue, and consequently on the shape of the sequestrum, the 
formation of the sequestrum is not the result of embolism. 

I need not repeat what I have previously said in connection 
with soft deposits as to the further progress of the disease when 
the tubercular process reaches the surface of the bone. The 
progress of events is practically the same in both cases. It 
does not, however, necessarily follow that once a soft deposit 
or a tubercular sequestrum has been formed the disease will 
continue to progress. I have examined several cases in which 
disease has evidently come to a standstill, and the deposit has 
become encapsuled by dense fibrous tissue or bone, or has 
become infiltrated with calcareous salts ; in some cases indeed 
the tubercular material has completely disappeared, and a mass 
of fibrous tissue has been found in its place. 



CHAPTER IV. 

TUBEKCULAB CHANGES IN AETICULAB CARTILAGE 
AND THE SUBFACE OF BONE. 

The most common tubercular affection of bone is tubercular 
destruction or caries of the surface of the bone. The term 
caries was originally applied to all destructive or ulcerative 
changes of the surface of bone, but of late it has been restricted 
to those changes of the superficial layers of bone which occur 
in connection with tubercular disease, and restricted in this 
way the term is a very convenient one. 

Caries of the articular ends of bones is never, so far as I have 
seen, the primary tubercular affection; it practically always 
occurs secondarily either to a deposit in the bone or to synovial 
disease. It is also a curious fact that even in the case of 
osseous deposits the growth of tubercles in the superficial 
cancelli of the bone in the neighbourhood of the deposit, and 
the destruction of the cartilage, only goes on to a comparatively 
slight extent, and in some cases not at all till the synovial 
membrane has become affected or the deposit has opened into 
the cavity of the joint, after which the disease progresses with 
great rapidity. We might have expected that in the case of 
a deposit immediately beneath the cartilage the tubercular 
growth would have spread along under the cartilage and caused 
its exfoliation from within. This, however, is not the case, at 
any rate not to any marked extent; the tubercular growth 
seems to be more or less confined within the deposit in the 
first instance, and not till it has formed a communication with 
the joint or reached the soft tissues does it seem to be liberated 
and free to spread over the whole part. As I have already 
pointed out when a tubercular deposit in the bone reaches the 



DESTRUCTION OF ARTICULAR CARTILAGE. 47 

articular surface, erosion of the cartilage occurs over it, a 
communication is formed with the joint, the synovial mem- 
brane becomes infected, and then the cartilage is attacked, and 
it is not as a rule till destruction of the cartilage has pro- 
gressed to a considerable extent that the surface of the bone is 
affected. We must, therefore, study the changes which occur 
in connection with the cartilage in the first instance. 

The naked eye appearances of the changes in cartilage are 
well known and consist chiefly in thinning, and complete dis- 
appearance of portions of the cartilage, its detachment in the 
form of thin shreds, often full of holes, or even of thicker 
masses ; in fact in some cases cartilage which shows very little 
alteration may be partially loose and movable on the subjacent 
bone. These changes generally commence and are most marked 
at points where the synovial membrane joins the cartilage as at 
the edges of the cartilage, or at the points of attachment of the 
crucial ligaments in the knee, in the neighbourhood of the 
ligamentum teres in the hip, &c. Its destruction may also 
begin in the neighbourhood of the opening of the tubercular 
osseous deposit, and the thinning of the cartilage is also well 
marked at points of pressure. 

As I have said the early changes in the cartilage are, as a 
rule, most marked at the points where the synovial membrane 
is reflected on to the cartilage, and we not unfrequently find 
that the cartilage is but slightly or not at all affected except at 
the margins where the soft tissue, continuous with the synovial 
membrane, is spreading over and destroying it from the surface. 
This was well seen in the section through the wrist joint (Fig. 
11, p. 38), where the synovial membrane was spreading over the 
cartilage of the radius and destroying it first at the margins. 
The first change which occurs is apparently the spread of 
vascular tissue over the surface of the cartilage, this tissue 
becoming thinner and thinner as we pass away from the edge. 
This is seen in Fig. 15, which is a photograph from the margin 
of the articular cartilage of the head of the femur, show- 



48 



CHANGES IN ARTICULAR CARTILAGE. 



ing commencing destruction of cartilage from the surface. 
Underneath this new tissue the cartilage capsules enlarge, the 
cells multiply, and ultimately the capsules come to communicate 
with the surrounding soft tissue. At the same time the inter- 
capsular or intercellular material apparently becomes split up 
into fibres which are in many cases continuous with the fibres 
of the connective tissue on the surface, and the nuclei of 
the cartilage cells become elongated or spindle shaped, and 
apparently form some at least of the nuclei of the fibrous 




jiipl/ 



V 




Fig. 15.— Shows the extension of the soft tissue over the surface 
of the cartilage getting thinner and thinner towards the right 
hand side, i.e., further from the point of reflection of the synovial 
membrane. 

tissue. This tissue which, in the first instance, may show no 
evidence of the presence of tubercle, soon presents, in most 
cases, the character of a tubercular infiltration or well-developed 
tubercles are formed in it. 

The process then which takes place at the margin of the 
cartilage is the extension of this new tissue in a thin layer 
over it, followed by changes in the cartilage itself, which lead 
to its conversion into fibro-cartilage and ultimately into fibrous 
tissue; the new tissue so formed becomes subsequently infil- 
trated with the tubercular growth and undergoes caseation. 



PITTING OF THE CARTILAGE. 49 

If now we study the changes which occur in the cartilage at 
a greater distance from the edge of the synovial membrane, we 
find that this extension of the soft tissue goes on for a 
considerable distance, but, as a whole, in quite a thin layer, 
while here and there greater growth has occurred, and the 
previously mentioned changes in the cartilage are taking place, 
and thus we come to have islets of soft material over the 
surface of the cartilage, separated by patches of but slightly 
altered cartilage and connected by a thin layer of soft tissue 




Fig. 16. — Shows the articular cartilage undergoing destruction 
from the surface, islets of soft tissue being formed giving rise to 
the pitted and sieve-like appearance so often present. 

on the surface of the cartilage. In this way the pitted or 
completely perforated appearance of the shreds of cartilage 
is produced. This condition is well seen in Fig. 16, where a 
number of these depressions are present. 

The chief destruction of the cartilage occurs from the 
surface in the manner just described, but we not unfrequently 
also observe somewhat similar changes in the deeper part, 
especially at the margins. In some cases also, osteitis without 
formation of tubercle, occurs in the superficial cancelli of 



50 CHANGES IN ARTICULAR CARTILAGE. 

the bone, and a certain, though slight, amount of soft tissue is 
formed between the bone and the cartilage, and this is what 
occurs in those cases where the cartilage can be moved over 
the surface of the bone. 

As a rule, when the deeper part is affected one of two things 
happens, viz., either from the margin of the cartilage or from the 
bottom of one of the excavations on the surface, the newly formed 
tissue spreads in between the cartilage and the bone, destroying 
the deeper part of the cartilage, detaching it, and leading to 
exfoliation of pieces of as yet unaltered or partially eroded 
cartilage ; or tubercles form in the superficial cancelli, destroy 
the superficial layer of the bone, and lead to erosion of the 
deeper part of the cartilage. This erosion of the cartilage from 
the deep surface is, however, usually only seen at the edges of 
the cartilage, and is neither so common nor so extensive as the 
destruction from the surface, and it is by no means uncommon 
to find the greater part of the surface of the cartilage converted 
into fibrous tissue and remains of unaltered cartilage still firmly 
adherent to the bone. 

This description differs from that generally received in 
assigning the chief changes to the surface of the cartilage; 
most writers state that the destruction of the cartilage com- 
mences next the bone, but this is clearly not the case, or else 
the specimens I have prepared have all been taken from excep- 
tional cases. That is, of course, absurd, and as a matter of fact, 
one of these complete sections is equal to a great many small 
ones. No doubt the error has arisen from the examination of 
the edge of the cartilage, where the process is most marked, and 
where we frequently see the spread of the soft tissue between 
the cartilage and the bone; but when we examine the whole. 
cartilage, we see that this deep destruction is very slight as 
compared with the processes that are taking place at the 
surface. 

Another mode of destruction of cartilage is seen in Fig. 17, 
which is a portion of a vertical section of the internal condyle 



DESTRUCTION OF CARTILAGE FROM BENEATH. 51 

of the femur from a ease of disease of the knee-joint of six 
months' duration, in which the disease was primarily synovial, 
and in which there was great thickening of the synovial 
membrane. The cartilage was intact, except at the margins, and 
at one spot towards the centre and anterior surface of the internal 
condyle of the femur, where there was a small depression on the 
surface. The photograph is taken from a vertical section of 




Fig. 17. — Destruction of articular cartilage from the deeper 
surface, flask-shaped processes containing fibrous tissue shooting 
into it from the cancellous spaces beneath. 

the end of the bone through this spot. We see that the depres- 
sion in the cartilage is due to destruction of the cartilage at 
this point, and before the celloidin was dissolved out one or two 
small detached fragments of cartilage were seen at the surface, 
but these have been lost in clearing the specimen. "We further 
see a number of flask-shaped spaces in the cartilage which, 
under a higher power, are found to be filled with young fibrous 
tissue. Some of these spaces communicate with the surface of 



52 CHANGES IN ARTICULAR CARTILAGE. 

the cartilage, either freely or by narrow channels, while the 
majority, and perhaps all, are connected with the superficial 
cancelli of the bone by similar channels. At various other 
points along the deeper part of the cartilage we see similar 
flask-like projections communicating with the bone, and where 
these occur the most superficial cancelli show osteitis. I have 
not been able to find any tubercles in the bone. In this 
instance we have undoubtedly destruction of the cartilage com- 
mencing from the deeper part in a manner totally different 
to that which I have previously described as the usual mode, 
and I have seen indications of a similar process in other 
specimens, though never to the same extent. 

Before leaving the subject of the changes in cartilage, I may 
refer to the important question whether cartilage can be the 
primary seat of the disease. As regards hyaline or articular carti- 
lage this may certainly be answered in the negative, but it is 
still an open question with regard to fibro-cartilage. In the 
case of the spine it was long thought, and is, I believe, still 
held by some, that the changes frequently commence in the 
intervertebral cartilages, but this is clearly not the case. In 
the knee-joint, however, Kocher has described, under the term 
" meniscitis f ungosa," what he believes to be primary tubercular 
disease of the semilunar cartilages, but there is no evidence 
that the disease did not begin in the synovial membrane in the 
neighbourhood of the cartilage, and spread on to it. 

Following the destruction of the cartilages, and in some cases 
beginning to a slight extent before the cartilages have dis- 
appeared we have the carious changes in bone. Eoughly 
speaking, we may say that clinically the articular ends of bones 
are 1 carious when the cartilages are destroyed, but examination 
of a number of specimens where the articular cartilages have 
disappeared, shows that the resulting state of matters varies 
much, and if we were to limit the term " caries " to tubercular 
disease of the surface of the bone itself, we should exclude 



CARIES. 53 

many cases which are clinically reckoned as caries. It will be 
best, therefore, to study in one group the various conditions 
which we find when the articular cartilage has disappeared. 

In some cases we find that the cartilages are absent, and that 
their place has been taken by fibrous tissue, but it is seldom 
that the whole surface is covered simply with fibrous tissue ; 
usually there are tubercles or tubercular tissue at some part, 
either at the free surface or in patches in the tissue. We may, 
however, find extensive tracts of fibrous tissue without any 
tubercles in it, or in the superficial cancelli of the bone. This 
is probably an early stage, found only shortly after the destruc- 
tion of the cartilage, for it is seldom that the process ceases at 
this stage, or that the new tissue does not become the seat of 
the development of tubercles, if, indeed, it has not been tuber- 
cular from the first. 

In other cases the material which replaces the cartilage is not 
fibrous, but is composed of young tissue in places undergoing 
caseation, and this caseation may be of considerable extent, 
although as yet the superficial shell of bone has not been 
broken through, and there is no true caries. The following are 
some of the common appearances met with in true tubercular 
caries. 

By far the most common type in my experience is that seen 
in the section of the head of the tibia, shown in Fig. 18. On 
the right hand side of the surface of the bone we see that the 
superficial cancelli are infiltrated to a depth of about one- 
eighth of an inch with dense tissue, which, on examination 
under a higher power, is found to be composed of tubercles and 
tubercular infiltration, undergoing caseation at the edge. Lying 
among this tubercular tissue we see the trabecular of the bone, 
which are considerably thicker than elsewhere, and have in parts 
become completely detached, and lie loose in the cheesy material. 
At some little distance from the tubercular layer the bone is in a 
condition of rarefying osteitis, but immediately beneath it the 
cancelli contain young fibrous tissue, and it is here that the 



54 CHANGES IN ARTICULAR CARTILAGE. 

thickening of the trabeculse is occurring. The process here is 
condensation of the superficial trabeculse, invasion with tuber- 
cular tissue, lacunar absorption and death of the thickened 
trabeculse, and rarefying osteitis beyond. It is curious that in 
most cases this rarefying osteitis occurs at a considerable 
distance from the surface, and often in patches, while between 
these patches and the carious surface there may be an interval 
of comparatively healthy tissue. 

This specimen also bears out very well what I have said 







JFlG. 18. — Section of head of tibia with a soft deposit under the 
cartilage. To the right of the upper surface the cartilage has dis- 
appeared, and the surface of the bone is carious. [See Text.) 

about destruction of cartilage in the neighbourhood of tuber- 
cular deposits. I have pointed out that although we might 
have expected that, in the neighbourhood of tubercular deposits 
in the bone, tubercles would readily form in the superficial 
cancelli of the bone, and destroy the cartilage from beneath, 
this was not, as a rule, the case. And here we see that the 
only piece of cartilage left, and the only part of the surface of 
the bone which has not yet undergone the carious change, is in 
the immediate neighbourhood of the primary osseous deposit. 



SCLEROSIS OF BONE IN CARIES. 



55 



In other cases, the sclerosis and new formation of bone 
preceding the tubercular growth in cases of caries is very well 
marked, as, for example, in Fig. 19, taken from the internal 
condyle of the femur. Here we see that there has been extensive 
destruction of the surface of the bone, which has been replaced 
by tubercular tissue, undergoing caseation at the edge. Beneath 







Fig. 19. — Section of the lower end of the femur, showing caries. 
The cartilage has disappeared, and a quantity of soft tissue con- 
taining tubercles is present. Beneath this a network of new bone 
has been formed. 

this layer of soft tissue there is a line of newly formed bone, 
presenting a reticular appearance, the meshes of which contain 
young fibrous tissue, not yet invaded by the tubercular growth. 
This sclerosis of bone in connection with caries sometimes 
goes on to a very marked extent, but, as a rule, such density of 



56 CHANGES IN ARTICULAR CARTILAGE. 

the bone beneath the carious surface is not common in joints 
except in that form of the disease which is termed caries sicca. 
It is very rare, however, to find no evidence at all of sclerosis 
of the affected bone. 

The following is, in a few words, what happens in the course 
of tubercular disease of the surface of bone. The first changes 
occur in connection with the cartilage, though in some cases, 
but more rarely, the superficial cancelli of the bone first show 
signs of osteitis, and still more rarely the presence of tubercles. 
The cartilage disappears in one of the modes formerly described, 
by far most commonly by the spread of tissue over the surface, 
and then we find the surface of the bone covered with young 
fibrous tissue containing tubercles, or with very vascular tissue 
containing tubercles, or with plain fibrous tissue. The tuber- 
cular growth soon extends into the superficial cancelli, and 
young fibrous tissue is formed beyond it, and sclerosis of the 
trabeculse occurs. As the tubercular invasion extends, portions 
of these osseous trabeculse become detached, and caseation 
takes place. Beneath the tubercular invasion there is usually 
a line of condensing osteitis of varying breadth, while further 
away there may or may not be rarefying osteitis, often in 
patches. ■ The amount of condensation underneath the carious 
part varies much in extent and character, the bone being, in 
rare cases, very dense, and in others not noticeably sclerosed. 
The sclerosis of the trabeculse in the carious part varies also in 
amount, and may even be entirely absent. By the continued ex- 
tension of these processes, the gradual destruction of the surface of 
the bone goes on, being naturally most marked at points subject 
to pressure. The presence of this thickening of the trabeculae, 
previous to the tubercular invasion, shows that active formative 
processes have been going on in the part, and that the death 
of the bone is not primarily a degenerative process, as various 
authors, such as Cornil and Banvier, have asserted, but usually 
follows a previous stage of hyperplasia. The detachment of 
the fragments occurs by lacunar absorption of portions of the 



DEPTH OF THE CARIOUS CHANGES. 57 

trabecular, and the reason why these fragments are frequently 
not absorbed is that, in these cases, caseation occurs too rapidly. 
Where caseation occurs more slowly, more or less complete 
absorption may take place, and we may find on the surface 
a layer of completely caseous material, without any fragments 
of bone. 

Of great clinical importance are the following facts, viz. : — 
the slight depth to which the actual tubercular disease extends, 
seldom more than \ of an inch, the tendency to sclerosis 
immediately beneath it, and the occurrence of rarefying osteitis 
at some distance away, and often in patches without any tuber- 
cular growth. It is very curious to note, in many cases, that a 
layer of comparatively normal cancelli separates the carious part 
from that where the rarefying osteitis is most marked, but of 
this fact I am unable to offer any rational explanation at 
present. 



CHAPTEK V. 

TUBERCULAE PERIOSTITIS AND TUBERCULAR 
OSTEOMYELITIS. 

So far I have been speaking of disease of the synovial membrane 
and the articular ends of bones ; but I must now shortly describe 
the course of events when the disease attacks bones at a distance 
from the articular surfaces, and I shall especially refer to disease 
of the short long bones, and also of the spongy bones. In 
this instance the disease may either begin on the surface of the 
bone in connection with the periosteum, or in the medulla of the 
bone — that is to say, we may either have a tubercular periostitis 
or a tubercular osteomyelitis. 

Tubercular periostitis as a primary affection occurs most 
frequently in the ribs and the vertebrae. In the case of the 
ribs tubercular disease may commence either in the interior of 
the bone or in the periosteum, in the latter most commonly. 
Where tubercular periostitis affects a rib, the bone at the seat 
of the disease soon becomes thinner than usual, and presents 
a worm-eaten appearance. This superficial erosion of the bone 
steadily progresses till a more or less marked defect in the bone 
is formed; indeed, such a bone not uncommonly fractures. 
This appearance is due to the fact that the tubercular new 
growth, occurring first in the deeper layers of the periosteum, 
soon spreads into the bone along the Haversian canals, fills up 
bhe superficial cancellous spaces, and causes erosion of the 
bone on the surface and also destruction beneath the surface, 
while sclerosis occurs in the neighbourhood. The disease 
spreads along the periosteum, and may involve a considerable 
extent of the bone, eating into it irregularly at various 
points. 



DISEASE OF THE VERTEBRAE. 



59 



Perhaps the most common seat of tubercular periostitis is 
the vertebrae. Tubercular disease of the vertebrae commences 
either in the substance of the bone as a circumscribed tuber- 
cular deposit or a more diffuse tubercular osteomyelitis, or on 
the surface as a tubercular periostitis. The latter is the 
most common form in adults ; it involves a number of bones, 
curvature is at first absent, and is seldom acute, and chronic 




Fig. 20 — Section of the body of a vertebra, showing caries of the 
surface (right hand side), resulting from a tubercular periostitis and 
great sclerosis of the bone beneath. 

abscess very frequently occurs. The character of the disease 
in this case is the same as that described under caries, and 
there is the same sclerosis of bone beneath. In Fig. 20 the 
carious condition of the surface, the result of the tubercular 
periostitis, and the sclerosis of the bone beneath, are well 
seen. 



60 PERIOSTITIS AND OSTEOMYEIITIS. 

In the case of the short long bones, such as the phalanges, 
with their metacarpal and metatarsal bones, the tubercular 
disease generally commences in the interior of the bone in the 
form of tubercular osteomyelitis, and it may either cause a 
general enlargement of the bone, with or without necrosis in 
the interior, or a more limited and more marked expansion of 
the bone, the condition typical of strumous dactylitis. The 
former is more often the case in adults, the latter in children. 

The disease in both cases commences in the medulla of the 
bones, and is very correctly described as a tubercular osteo- 
myelitis. In some cases it is accompanied by sclerosis and 
new formation of bone, going on to the production of a seques- 
trum, but the sequestra in these cases are seldom so entirely 
dense as those in the ends of the long bones ; more usually they 
have undergone a good deal of absorption, being thus in parts 
dense and in parts soft. 

More often, however, tubercular osteomyelitis results in the 
formation of an extensive soft mass in the interior of the bone, 
which is, nevertheless, not so well circumscribed as the soft 
deposits in the ends of the long bones, which I have previously 
described, and we frequently find in these cases that the tuber- 
cular growth spreads for a considerable distance along the 
medulla of the bone, leading to great sclerosis, and sometimes 
necrosis of the shaft outside. This infiltrating tubercular 
growth also occurs in the bodies of the vertebra, and in the 
smaller spongy bones, especially in those of the tarsus, but not 
so often as the circumscribed deposits, while it is rare in the 
epiphyses of the long bones. 

Fig. 21 is an excellent example of tubercular osteomyelitis, 
with sequestrum formation. It is a complete section through 
the first phalanx of a finger of a lady, aged twenty-eight, who 
was also suffering from phthisis. There was a sinus on the 
inner side of the finger leading to the front of the bone. On 
examining the specimen we see marked enlargement, more 
especially of the middle of the bone, in the interior of which is 



TUBERCULAR OSTEOMYELITIS. 61 

a cavity containing cheesy material and a sequestrum. This 
sequestrum is in parts much thickened, and in other parts 
partially absorbed, the spaces being filled with caseating mate- 
rial. Surrounding the caseating wall of the cavity is a layer 

of tissue containing tubercles 
either isolated or in the form of 
tubercular infiltration. Beyond 
this we have a layer of much 
thickened trabecule, which are 
becoming eroded on the side 
towards the concavity by the 
tubercular growth. Beyond 
this layer of thickened and 
newly formed trabecule, we 
have at the proximal end fairly 
normal tissue. Towards the 
distal end of the phalanx there 
are one or two tubercles in 
the cancelli, and in some of 
the sections the tubercular 
growth is beginning to creep 
over the cartilage at the an- 
terior part. This cavity in 
the bone communicates freely 
with the surface anteriorly, 
the bone being entirely ab- 
sorbed there, and the tuber- 
cular tissue is infiltrating the 
soft parts. The posterior part 
of the bone is also destroyed 
at one or two places leading to 
the formation of holes communicating with the soft tissues 
outside. 

The most common form of tubercular osteomyelitis in young 
children is seen in strumous dactylitis. "We do not usually have 




Fig. 21. — Section of a phalanx show 
ing a tubercular sequestrum in th< 
substance of the bone. {See Text.) 



62 



PERIOSTITIS AND OSTEOMYELITIS. 



the opportunity of examining' these cases thoroughly, because 
amputation is but rarely necessary, and certainly not in the early 
stage, where the appearances would be most typical. I have, 
however, obtained a specimen of the lower end of the ulna, 
which presented this form of the disease (see Fig. 22). The 




Fig. 22. — Section of the lower end of the ulna, showing tubercular 
osteomyelitis. The soft tissue in the centre has fallen out. The 
new bone both in the shaft and in the periosteum is well seen. 

patient was a child, aged six, who suffered also from disease of 
the elbow joint. The lower end of the ulna was much dilated just 
above its termination, the centre of the bone being filled with 
soft tissue, which has for the most part fallen out in preparing 
the sections. We see that lining this cavity there is a layer of 



STRUMOUS DACTYLITIS. 63 

soft material which is fibrous in character, and which contains 
a few tubercles. Surrounding this cavity the osseous trabecule 
are thickened, and in several places new trabecular have been 
formed, and are arranged in a peculiar reticulated manner. The 
cancelli of the bone contain fibrous material. Corresponding 
to the most thinned and dilated part of the bone, there is new 
formation of bone from the periosteum. 

The process is essentially the same as that seen in some of 
the other cases of tubercular disease of bones previously des- 
cribed, viz., the deposit of tubercles in the medulla of the bone, 
a formative inflammation around resulting in the production of 
fibrous tissue, thickening of existing trabecular and formation 
of new trabecular, subsequent invasion of this newly formed 
tissue by the tubercular growth, and consequent absorption of 
the trabecular. This process is accompanied by great enlarge- 
ment of the bone which again becomes thinned from the in- 
terior, and also by new formation of bone from the periosteum. 
By and by the shell of the bone disappears at one or more 
points and a communication forms externally. This is simply 
an exaggerated form of the soft deposits in the ends of bones, 
and just as these are more frequent than necrosis in children 
so this spina ventosa is more frequent in young people than the 
form of tubercular osteomyelitis accompanied by necrosis. 

A special investigation, and one worth mentioning, has been 
made by Eenken as to the tubercular nature of the soft 
material in the interior of the bone in these cases of strumous 
dactylitis. In five cases he examined this soft material micro- 
scopically for tubercle bacilli, and at the same time inoculated 
guinea-pigs from each case. In every instance he found bacilli, 
though usually in small numbers, and all the guinea-pigs 
became tubercular. That the disease in the guinea-pigs was due 
to the inoculation was shown by the fact that the disease com- 
menced at and spread from the seat of inoculation, and also by 
the fact that other animals not inoculated but kept in the same 
cages with those experimented on did not become tubercular. 



CHAPTEK VI. 

RAKER FORMS OF TUBERCULAR BONE DISEASE. 

caries sicca; diffuse condensation of bone in connection 
with tubercular. disease; diffuse softening of bone 
and the formation of " red marrow." 

1. Caries Sicca. 

This is a rare form of tubercular disease of bone which chiefly 
affects the shoulder-joint, though it sometimes occurs in the 
hip, and more rarely in the knee. It is seldom accompanied by 
suppuration, and is characterised by a marked and peculiar 
atrophy of the bone and by obliteration of the articular cavity. 

The term " caries sicca " was first used by Carabelli in con- 
nection with disease of the teeth, and was subsequently applied 
by Wagner to certain diseases of bone. The writer who first 
brought this type of disease into prominence' was, however, 
Volkmann, who calls it " an inflammatory atrophy of bone," 
and at first he was not inclined to look on it as tubercular. 
More careful microscopical examination has, however, shown 
that the disease is in reality tubercular, although considerable 
tracts of the tissue in the bone may not show any tubercular 
invasion. Tubercle bacilli have been demonstrated in the 
affected tissues by Wanke in 1884, and by Gutenberg in 1886, 
and a further proof of its tubercular nature is furnished by 
the great frequency with which these patients develop tuber- 
culosis elsewhere, especially in the lungs. 

I may, in a few words, sketch the clinical history of this type 
of tubercular disease, say in the shoulder-joint. The disease, as 
a rule, develops without any apparent cause in' young and 



CARIES SICCA. f>5 

frequently healthy individuals ; in some cases, however, it 
follows a sprain or blow. The earliest symptoms are the 
occurrence of pain, which is often looked on as rheumatic, and 
diminished range of movement, any attempts at which give 
rise to pain. The pain usually becomes severe after a time, and 
not unfrequently extends down the arm in the form of neuralgia. 
There is no swelling of the part, but on the contrary there is 
gradually increasing atrophy of the whole of the structures 
around the shoulder. The acromion projects markedly while 
the head of the bone becomes so small that it may not be felt. 
The stiffness of the joint constantly increases, and attempts 
at movement cause great pain and a crackling sensation. 
The disease goes on without suppuration or fever till ulti- 
mately after one or two years it may cease and leave firm 
anchylosis of the joint. In some cases chronic abscesses occur, 
but they are generally of small size and extra-articular, and 
Volkmann thinks that the cases in which this takes place are 
those where a sequestrum has formed and projects into the 
remains of the joint cavity. 

If we compare the anatomical structure of caries sicca with 
the usual appearances in ordinary caries, we find that instead 
of soft caseous material or luxuriously growing dark red or 
oedematous granulations on the surface of the bone, and only 
loosely connected with the underlying tissue we have a small 
quantity, often only found with difficulty, of a tissue which is 
very slightly vascular, which at times is almost cartilaginous, and 
which is so intimately connected with the bone that consider- 
able force is required to detach it. 

The process consists essentially in the formation of dense 
tubercular tissue which causes erosion of the cartilage and bone, 
and leads to irregular losses of substance; similar tissue also 
develops from the synovial membrane, grows inwards between 
the joint surfaces, and leads to obliteration of the cavity. The 
peculiarity of the new tissue in this disease is its great 
tendency to shrink and form firm fibrous tissue. 



66 RARER FORMS OF TUBERCULAR BONE DISEASE. 

In addition to the disappearance of the bone as a result of the 
growth of this dense granulation tissue, there is also a general 
atrophy of the bone of a concentric character, as Volkmann has 
pointed out, and the narrowing of the neck of the humerus is some- 
times very marked. The disappearance of the bone occurs chiefly 
under the cartilage, and a considerable tract of cartilage may 
still be retained over an extensive loss of the substance of the 
bone. In that case the cartilage generally becomes bent in over 
the defect, so that instead of a rounded head to the bone the 
head is irregular and mis-shapen. 

2. Diffuse Condensation of Bone in connection with 
Tubercular Disease. 

These cases are rare, but it sometimes happens, and I have 
seen it more than once, that on opening up a sinus leading to 
the shaft of a bone and scraping or gouging away a portion of 
the bone, we see dense yellow bone extending along the shaft 
for a considerable distance, and showing no limiting line between 
healthy and diseased parts. This condition has been looked on 
as a tubercular infiltration of the bone and sclerosis, and cer- 
tainly to the naked eye it looks very much as if the substance 
of the bone were infiltrated with tubercular tissue undergoing 
caseation. This, however, is not, as a rule, the case. 

Not long ago I had an excellent example of this form. 
The patient was a male aged twenty-seven, who sprained 
his knee twelve months before admission, and this was 
followed by pain and the formation of a chronic abscess. 
When admitted, the ends of the bones were thickened, there 
was swelling of the synovial membrane, and sinuses seemed 
to lead not only to friable bare bone, but also into the joint. 
Amputation was performed about sixteen months after the 
commencement of the disease. 

On making a section of the bones in a fresh state the greater 
part of the lower end of the femur, extending well up the shaft 



NON-TUBERCULAR CONDENSATION OF BONE. 67 

and especially towards the outer side, presented a dense yellow 
appearance. The articular cartilage was gone over the front and 
sides of the femur at the parts where this yellow material reached 
the surface, but at other parts it was still intact, and there was 
little or no soft tissue on the surface of the bone. The synovial 
membrane was firm and only moderately thickened. On the 
outer side of the external condyle of the femur there was a 
partially separated sequestrum; this sequestrum was outside 
the joint and the sinuses led to it. The medulla of the lower 
end of the femur presented this same dense yellow appearance. 
Surrounding the necrotic fragment there was a layer of 
glistening gelatinous material and around this an area of 
dusky congestion. The head of the tibia was not much affected 
on the outer side, but in the centre of the internal tuberosity 
there was a similar yellow patch ; the articular cartilage of the 
tibia was intact. The patella was much atrophied, being about 
one-half its normal size. A section of the femur showed 
moderately thickened trabeculse with caseous material in the 
meshes. In the bone surrounding the sequestrum were 
tubercles and tubercular infiltration to the depth of about one 
eighth of an inch. The rest of the shaft showed a certain 
amount of new formation of trabeculae and thickening of the 
older ones, and the meshes were filled with young fibrous tissue 
which, in most places, was undergoing fatty degeneration. 
Except in the immediate vicinity of the sequestrum there was 
no tubercular tissue in the bone. Towards the periphery of the 
bone, however, there was distinct rarefaction. There was 
commencing destruction of the articular cartilage at the edge 
next the tubercular deposit. 

The sequence of events was, I believe, the following: — A 
tubercular deposit formed near the surface of the external 
condyle of the femur and led to the production of a sequestrum. 
Around this deposit condensing osteitis occurred and extended 
over the bone for a considerable distance, but before very long 
fatty degeneration of the inflammatory products took place and 



68 RARER FORMS OF TUBERCULAR BONE DISEASE. 

reached an extreme degree, and calcareous salts were also 
deposited in this fatty material. "Where this fatty degeneration 
extended quite up to the cartilage the latter was deprived of 
nutritive material and became rubbed or broken away at the 
surface. The obstinacy of these cases is thus due to the fatty 
degeneration of the tissue and not to tubercular infiltration 
of the bone. 

3. Diffuse Softening of Bone and the Formation of 
"Bed Maekow." 

The other diffuse change of bone in connection with tuber- 
cular disease of the ends of bones is the opposite condition of 
diffuse softening of the bone. This condition has been described 
by other authors, and is also rare. In it we find disappearance 
of the osseous trabecule in the epiphyses and medulla of the bone 
and thinning of the shell of the bone, the medullary cavity 
being thus much enlarged and filled with red marrow. Several 
authors who have examined this tissue state that tubercles are 
frequently found scattered through it in considerable numbers. 
This is a very bad type of the disease, as a number of bones are 
usually involved and general tuberculosis is very apt to occur. 

I have only come across one specimen of this kind, obtained 
from a patient who was under the care of a colleague. The 
case was that of a child who had previously suffered from 
tubercular disease of the elbow, ulna and finger, and whose leg 
was amputated at the knee for disease of the joint. The child 
ultimately died of general tuberculosis, and the medulla of the 
bones was red, soft, and, in fact, almost diffluent. All attempts 
to obtain complete sections of the medulla and bone failed 
on account of the softness of the tissue, and therefore I 
had to content myself with sections of small portions. When 
stained with methylene blue the medulla was seen to be 
composed of a mass of cells of various shapes and sizes running 
among which were strands of fibrous tissue. Here and there 
were light stained tracts of large cells bordered by groups of 



DIFFUSE SOFTENING OF BONE. 69 

small cells. The nuclei of these large cells were faintly stained 
and of an oval form, and it is possible that they may represent 
tracts of tubercular infiltration. The appearance, however, is 
not absolutely characteristic, and in none of the specimens did 
I find any isolated tubercles. It seems to me probable that 
in some, at least, of these cases the softening of the bone is 
purely the result of an extreme degree of rarefying osteitis in 
the neighbourhood of tubercular disease, thus being the 
converse of the preceding condition. 



CHAPTEE VII. 

PATHOLOGY OF CHRONIC ABSCESS. 

In what I have previously said, I have retained the terms 
" chronic abscess," " suppuration," and " pus " in connection with 
these tubercular diseases, although, as a matter of fact, these 
terms are incorrect; for when we speak of suppuration or 
chronic abscess in connection with tubercular processes, we do 
not mean the same pathological process as in ordinary suppura- 
tion and acute abscess, nevertheless, the terms are so incorpor- 
ated with medical literature that it is hardly possible to give 
them up, more especially as it is by no means easy to find a 
suitable short word as a substitute. There need, however, be 
no confusion if we bear in mind their meaning, and in the 
following pages, when I speak of suppuration and abscess in 
connection with tubercular diseases, I mean the process to be 
presently described, while if I refer to true suppuration, I 
speak of it as " acute " or " septic suppuration." 

The process of chronic suppuration will be best understood 
if we trace the development of a chronic abscess in the soft 
parts. The earliest commencement of these abscesses in the 
cellular tissue is the formation of a small firm nodule, which 
steadily, though slowly, increases in size. After a time (when it 
has attained, for example, the size of a nut or pigeon's egg, 
sometimes earlier), the centre softens, the swelling increases 
more rapidly, and the contents become fluid, in fact, a chronic 
abscess has been formed. 

If we examine such a nodule in the early stage, we find that 
it consists of a mass of tubercles which, at the oldest part, have 
become confluent. At this period, as seen in Fig. 23, caseation 
begins, and a collection of caseous material is formed surrounded 



COMMENCEMENT OF CHRONIC ABSCESS. 71 

by tubercular tissue. This caseous material becomes infiltrated 
with fluid, and also with some leucocytes, and thus we have a 
cavity containing fluid, fatty material, fragments of cells and 
leucocytes, and around this cavity tissue showing tubercular 
infiltration, and further away isolated tubercles. At the spread- 
ing margin the tubercular tissue continues to invade the 
surrounding structures, while not only does the caseation extend 
around the original cavity, but it also commences in inde- 




Fig. 23. — Earliest commencement of a chronic abscess. The 
tubercles have run together, and this tissue is undergoing caseation ; 
fluid is being effused among this caseous material. 

pendent parts of the wall. These , fresh caseous centres 
ultimately communicate with the original cavity, and thus we 
have produced the ragged appearance of the wall well shown 
in Fig. 24, which represents a complete section through the wall 
of a chronic abscess, and in which we see the ragged appearance 
of the part next the abscess cavity, where the darker portions 
in the wall, which are numerous, are points where caseation is 



72 



PATHOLOGY OF CHRONIC ABSCESS. 



occurring. As a result of the formation of these isolated caseous 
deposits in the wall, portions which have not yet completely 
caseated become detached and fall into the general cavity, 
forming the flakes and masses so constantly present in chronic 
abscesses. 

These abscesses extend by fresh growth of the tubercular 
tissue in the surrounding parts, while caseation goes on in the 




Fig. 24.- 



-Section of a small chronic abscess hardly magnified. 
(See Text.) 



centre. Hence, whatever part of the wall of a chronic abscess 
is examined, caseating tubercular tissue and frequently isolated 
tubercles will be found, as seen in Fig. 25, which is taken from 
the wall of the abscess shown under a low power in Fig. 24. 
Here we see three tubercles with large giant cells, and the tissue 
in the neighbourhood is infiltrated with epithelioid and giant 
cells. When the abscess bursts externally, or is opened, a sinus 



CHRONIC SUPPURATION IN JOINTS. 73 

is left, in the wall of which tubercles and tubercular tissue are 
present. 

Exactly the same process occurs in connection with tubercular 
disease of bones and joints. When suppuration occurs in a 
joint in connection with tubercular disease the layer of tuber- 
cles on the inner surface of the synovial membrane caseates, the 
caseous material falls into the cavity of the joint, fluid is poured 
out, and leucocytes also pass out in varying numbers. Where 




Re. 25. — Magnified section of the wall of a chronic abscess (Fig. 
24), showing the presence of tubercles with large giant cells. 

the abscess forms in the substance of the synovial membrane a 
tract of tubercular tissue caseates, and the abscess spreads in 
the manner formerly described. Where a tubercular osseous 
deposit makes its way to the surface, it infects the periosteum 
over it, destroys it, and then spreads in the cellular tissue. In 
such a case part of the wall of the abscess is formed by the 
carious surface of the bone. 
Konig ascribes an important rdle to fibrin in the formation 



74 PATHOLOGY OF CHRONIC ABSCESS. 

of the walls of chronic abscesses, and in the thickening of the 
synovial membrane. He says that fibrin is poured out and 
coagulates on the free surface of the cavity, that granulation 
cells spread into this layer, and tubercles appear in the granula- 
tion tissue, fresh layers of fibrin are deposited, and thus the 
process goes on. This pathology will be seen to be quite 
different from the foregoing, but in my opinion it is erroneous. 
A careful study of complete sections of diseased synovial mem- 
brane, and of the walls of chronic abscesses will, I think, show 
that the description I have given is correct. There can be no 
mistaking the fact that the granular material on the inner 
surface of the walls of chronic abscesses and of tubercular 
synovial membrane is, in the great majority of the cases, 
derived from the degeneration of preformed tissue, and is not 
due solely or even chiefly to fresh deposit of fibrin on the 
surface, for the whole series of changes can be demonstrated. 

While, as we have seen, caseation of the tubercular growth 
plays a very important part in the formation of chronic abscess, 
we must not, therefore, suppose that chronic suppuration is the 
same thing as caseation, or that these are convertible terms. 
In chronic abscess we have, in addition to caseation of the 
affected tissues, effusion of fluid and formation of pus cells, 
sometimes in very large numbers, in fact, there is more or 
less acute inflammation, superadded to the tubercular process. 
Caseation is a very constant occurrence in tubercular growths, 
while chronic suppuration is by no means always present. 
Hence it is evident that some additional factor must come into 
play in determining the occurrence of chronic abscess. Some 
investigators have suggested that they owe their first formation 
to the ordinary pyogenic cocci which settle in the affected tissue 
and cause suppuration, and that afterwards these organisms die 
out. Apart from the fact that the character of the contents 
of these abscesses differs from that of the contents of acute 
abscesses, the early symptoms of chronic abscess do not present 
the acute character which we should expect if the pyogenic 



ETIOLOGY. 75 

organisms were at work, while chronic abscesses have been 
examined, and I have myself done this, at a very early period, 
without finding any other organisms than tubercle bacilli. 
Further, as Garre has pointed out, pyogenic organisms grow 
luxuriantly in the pus of chronic abscesses, while they do not 
do so in pus which has previously been the seat of their growth. 
And further, these cocci do not die so rapidly as we must 
assume to be the case, in order to account for their absence from 
the contents of these abscesses, for they can retain their vitality 
for months in the same material. I do not think that we can, 
at the present time, give any thoroughly satisfactory explana- 
tion of the occurrence or absence of chronic abscesses in 
connection with tubercular diseases of bones and joints. I 
believe that it has to do with the constitution of the patient, 
whatever that term may imply, that is to say, that the factor or 
factors at work do not come directly from without. These 
chronic abscesses are most common in patients who have a 
hereditary tubercular history, in patients who suffer from 
multiple tubercular affections, in patients who have fallen into 
a low state of health, in patients where there has been exacerba- 
tion of the local trouble as the result of injury, &c. The more 
definite meaning of these facts must be left for future research, 
but none the less we must bear in mind the tubercular nature 
of the abscesses, and the fact that the whole wall is infected 
and infective, and therefore in treating them we must pay 
attention to this wall, and, if possible, try in some way or other 
to render it innocuous. 



CHAPTEE VIII. 

THE TUBERCTTLAK NATURE OF " STKUMOUS ' 
JOINT DISEASES. 

At the end of the first chapter, I summarised the chief reasons 
for regarding " strumous " bone and joint disease as tubercular, 
and I propose now to enter a little more fully into this matter. 

In the first place, many cases are now on record where 
wounds have become accidentally infected with tuberculosis, 
and where subsequently various diseases known as " strumous " 
affections have developed. I may mention a few examples 
where bone and joint disease developed after the injury. 

Verneuil mentions the case of a student who injured the fold 
of the nail of his right ring finger at a post-mortem examination, 
with the result that a post-mortem wart developed. This was 
treated in various ways without permanent improvement, and 
after three years' treatment there was still a tubercular ulcer 
on the finger, and a tubercular abscess on the back of the hand. 
This abscess was opened, and the ring finger was amputated, 
but chronic abscesses formed from time to time elsewhere, and 
the patient ultimately died six years after the injury of spinal 
meningitis, due to suppuration in connection with tubercular 
disease of the vertebra;. 

Czerny mentions two cases where skin grafting was employed 
in large ulcers, the skin being taken from limbs just amputated 
on account of tubercular bone disease, and these patients after- 
wards became the subjects of tubercular disease. In the one 
case, the surface of the wound, which extended from the foot to 
above the knee, became covered with croupous unhealthy mem- 
brane, and the granulations became weak and cedematous. 
After some time a communication formed with the knee-joint ; 



CASES OF ACCIDENTAL INFECTION. 77 

this sinus closed, and opened again several times, and the patient 
died of phthisis fourteen months later, but there were no definite 
signs of disease of the knee-joint. In the other case, the sore 
was over the thorax, and after a time the patient developed 
spinal disease with curvature and psoas abscess. 

In Middeldorpf's case the patient, a male, aged sixteen, 
healthy, and with no hereditary tendency to phthisis, received a 
penetrating wound of his knee-joint, to which he applied his 
handkerchief, and which healed in eight days. Fourteen days 
after the accident, swelling of the joint was noticed, with great 
pain on movement. During the following four weeks he suffered 
great pain, and had starting of the limb at night, &c, and his 
condition six weeks after the accident was that there was a scar 
below the patella, great thickening of the synovial membrane, 
and slight dulness at the apex of the right lung. Excision was 
performed, and the synovial membrane was found to be greatly 
thickened, but there was no disease of the bone. Tubercle 
bacilli were found in the synovial membrane. Micldeldorpf 
assumes this to be a case of inoculation either from the axe or 
from the handkerchief, chiefly because the patient's previous 
health was good, because the course was rapid, and because the 
time which elapsed between the injury and the commencement 
of the symptoms, fourteen days, is about the usual period of 
incubation. 

Pfeiffer reports a case of a healthy veterinary surgeon with a 
good family history, who, while dissecting a tubercular cow, 
punctured the phalangeal joint of his left thumb. The wound 
soon healed, but induration of the scar took place, and later the 
whole joint became swollen, and presented the typical appear- 
ance of a scrofulous synovitis, but without the formation of 
sinuses. Some months later the patient began to show signs of 
pulmonary phthisis, which rapidly increased, and he died of this 
disease a year and a half after the injury. The thumb, which 
was much swollen, but with the skin unbroken, was removed 
for examination. The joint, on being laid open, showed all 



78 NATURE OF "STRUMOUS" JOINT DISEASES. 

the destructive changes of scrofula both in the bones and 
synovial membrane ; and in the latter, as well as in the broken 
down material which filled the interval between the bones, an 
unusually large number of tubercle bacilli was present. The 
microscopical appearance of the diseased tissues was also typically 
tubercular. 

Barner has also published a case of joint disease secondary to 
a post-mortem wart on the hand. His case was that of an 
assistant in the post-mortem room, aged fifty-four, with a good 
family history, who first contracted these warty growths ten to 
fourteen years previously, and at that time they healed. Seven 
or eight years before the date of admission, he acquired another 
wart, which, however, disappeared under treatment, but had 
previously extended to the carpo-metacarpal joint. This was 
followed by tubercular disease of the carpus, for which excision 
was performed. 

A second proof that these strumous diseases are truly tuber- 
cular is afforded by the microscopical structure of the tissues 
affected. In all these affections, tubercles and tubercular tissue 
are constantly present in the thickened synovial membrane, the 
osseous deposits, &c, and present all the characteristics already 
described. The results which I have obtained are similar 
to those of other observers ; to mention one example, Konig 
examined 72 specimens in the Gottingen Museum, and, of 
these, 67 yielded fairly satisfactory results. He found tubercles 
in bones and joints, in the walls of chronic abscesses, and in the 
soft tissues at the points of reflection of the synovial membrane, 
and he points out that the- characteristic tubercular tissue is 
not seen in ordinary granulations, acute osteomyelitis, &c. 

The tubercular nature of these diseases of bones and joints is 
further and definitely shown by the presence of the tubercle 
bacillus. As is now well known, tubercle bacilli are never 
found except in connection with tubercular tissues, and when 



PRESENCE OF TUBERCLE BACILLI. 79 

we bear in mind the experimental evidence and the role which 
this organism plays in the production of tubercle, we must 
assume that, whenever we find tubercle bacilli in a morbid 
tissue, the disease with which we have to do is tuberculosis. 
Search has accordingly been made for these bacilli in the 
diseased tissues, and in the caseous material or pus, with the 
following results — ■ 

Koch, in his first work on tuberculosis, stated that he had 
found tubercle bacilli in small numbers in 4 cases of strumous 
disease of joints, in 3 cases of strumous glands, and in lupus. 

Schuchardt and Krause were the first to make an elaborate 
investigation on this subject, and they carefully examined 40 
cases of surgical tuberculosis in patients of various ages, and 
with and without hereditary taint, the diseases to which they 
directed their attention affecting bones, joints, sheaths of 
tendons, skin, including lupus, walls of tubercular abscesses, 
lymphatic glands, tuberculosis of tongue, testicle, uterus, and 
Fallopian tubes. Tubercle bacilli were found in all these 
parts, but in the great majority of instances they were 
few in number, and only found after a long search. These 
authors thought that the small number of the organisms was 
due to the fact that these diseases are very chronic, and they 
supposed that the bacilli are most numerous in the early stage, 
although, as a matter of fact, they had no absolute evidence in 
support of this view. 

These observations have been repeated by several other 
observers with varying results. Thus, Bouilly always succeeded 
in finding bacilli, though only after a long search. Mogling 
examined in all 53 specimens, of which 28 were from joints 
or bones, and he also obtained positive results, though the 
bacilli were, as a rule, present only in small numbers, nor were 
they specially limited to the giant cells, as had been asserted 
by earlier observers. Kanzler confirmed these statements. 
Schlegtendal, employing Ehrlich's method, examined the con- 
tents of 23 abscesses connected with bones and joints, and 



80 NATURE OF "STRUMOUS" JOINT DISEASES. 

obtained 8 positive and 15 negative results, but he did not 
examine the walls of the abscesses. In the discharge from 
fistuls connected with bones and joints, 7 positive results were 
obtained in 46 cases. In all, including abscesses and sinuses 
connected with disease of the soft parts, 17 positive results 
were obtained with the pus of 40 unopened abscesses, and 9 
with the discharge of 60 fistulse or ulcers. 

Midler examined from 30 to 35 cases of tubercular disease 
of bones and joints, the specimens being chiefly obtained by 
excision, and he confirmed Schuchardt and Krause's statement 
that, with patience, it is possible in most cases to find bacilli. 

In several cases where recovery was taking place, he looked 
in vain for bacilli. His investigations do not add any support 
to the view that the bacilli are most numerous in the early 
stage of the disease, but he states that, in many preparations, 
whether bacilli were present or not, there were peculiar bodies 
like drops of oil which retained the red stain, and which he 
looks on as probably remnants of bacilli. 

I have, on repeated occasions, examined the pus, bones, 
synovial membrane, &c, from strumous joints, for tubercle 
bacilli, but as I have not always kept notes of the cases I 
cannot give the precise figures. The general result of my 
examinations has been that, after sufficiently careful and pro- 
longed search, bacilli could always be found, but that, in most 
cases, they were extremely few in number. 

That the bacilli are present even when difficult to demonstrate 
by means of the microscope is evident from cultivation experi- 
ments, and from the results of inoculation of animals, but it is 
not easy to explain their apparent small numbers, and various 
theories have been advanced. Some authors suppose that the 
bacilli are most numerous at the commencement of the disease, 
and subsequently decrease in numbers. According to others, 
they rapidly pass into the spore stage, and are then no 
longer recognisable by means of the microscope. My own 
belief is that we do not as yet possess a method by which we 



BACILLI IN TUBERCULAR TISSUE. 81 

can stain all these bacilli at all stages of growth. I found very- 
early in working with the tubercle bacillus that if we took 
sections, say from rabbits, in which large numbers of bacilli 
were present, and stained them in simple watery solution of 
fuchsine, without any aniline, carbolic acid, or other similar 
body, a considerable number took up the stain, and a few 
retained it even after a short immersion in the dilute nitric 
acid. Thus it was evident that the staining reactions of these 
bacilli differ even in the same specimen, and this is, I think, due 
to differences in the age and stage of growth of the organisms. 
At a certain age or stage of growth the sheath is probably 
more easily penetrated by the stain than at another age, and 
this corresponds with what we know with regard to other 
organisms. Thus, in the case of anthrax, stained by Gram's 
method (gentian violet, iodine, and vesuvin, or other contrast 
dye), it is by no means uncommon to find some of the bacilli 
violet and others brown ; indeed, I have frequently seen some 
members of a chain violet, while others in the same chain were 
brown. In sections of tubercular synovial membrane, stained 
by Ehrlich's method (bacilli red, tissues blue), I have not 
uncommonly found that while a few red-stained bacilli were 
present, there were also some which were blue, but which 
nevertheless presented the same microscopical appearance as 
the tubercle bacilli, and bore the same relation to the giant 
and epithelioid cells, and I have no doubt whatever that these 
are, in reality, tubercle bacilli in a different stage of develop- 
ment. The first case where this idea occurred to me was that 
of an undoubted tubercular ulcer of the tongue, in which I 
failed to find any red-stained bacilli, but, on the contrary, 
considerable numbers of faintly stained blue organisms, resem- 
bling tubercle bacilli both in their situation and microscopical 
characters. Since that time I have paid great attention to this 
matter, and have seldom failed in well-stained specimens from 
tubercular joints to find blue-stained tubercle bacilli, often in 
larger numbers than those stained red. I believe, therefore, 
6 



82 NATURE OF "STRUMOUS" JOINT DISEASES. 

that the apparently small numher of tubercle bacilli in these 
local tuberculoses is mainly due to the fact that they are 
growing slowly and with difficulty, and that their staining 
reactions differ at different periods of their existence. We 
require further research as to the methods of staining of these 
organisms before we can conclude, because we fail to find them 
by the ordinary methods of staining, that they are therefore 
either absent or in the spore stage. 

In connection with this matter it is interesting to note that 
I have found the same difficulty in finding tubercle bacilli in 
the synovial membrane of animals, in which I have set up 
typical tubercular joint disease by the injection of pure culti- 
vations of tubercle bacilli, although they were easily demon- 
strated in the tubercles in the internal organs. 

To sum up, we may take it that only few bacilli can, as a 
rule, be demonstrated in tubercular joints and abscesses, but 
that they can usually be found in cases where the disease 
is progressing if the search be sufficiently careful and pro- 
longed, and, further, that our present methods of staining 
do not permit us to draw conclusions as to the numbers 
present. 

Another point which supports the view of the tubercular 
nature of these diseases is their frequent association with 
phthisis, tubercular meningitis, &c. It is a well-known fact 
that many patients suffering from strumous joint diseases are 
affected, or are very liable to become affected, with phthisis, 
while tubercular meningitis and general tuberculosis are, 
unfortunately, by no means rare terminations of these diseases, 
especially after operation or injury. 

It is difficult to ascertain the frequency of general tubercu- 
losis, phthisis, &c, in cases of tubercular joint disease, for 
patients who, when discharged, showed no symptoms of phthisis, 
may and often do develop it in later life. In my own statistics 
many of the cases were not under observation for a sufficient 



ASSOCIATION WITH PHTHISIS, ETC. 83 

length of time to be of value in determining this point; the 
average duration of the disease up to the termination of the 
treatment was nearly three years, and we find that during this 
time, of 386 patients, 42, or 10'8 per cent., had become affected 
with or had died of phthisis or tubercular meningitis. Of a 
large number of statistics which have been published, I may 
mention the following : — Billroth and Menzel found, on search- 
ing the post-mortem records at Vienna for a period of fifty years 
(1817-1867), that there had been 2106 cases of carious disease 
of bones and joints, and of these more than half (1143, or 52 
per cent.) were complicated with tuberculosis of the internal 
organs. It must, however, be noted that these were chiefly 
adults, and also that the post-mortem examinations were made at 
a time when the views on tuberculosis were very imperfect. In 
Billroth's Zurich statistics, extending over a period of seven 
years (1860-67), he operated on 71 cases, of which 26, or over 
36 per cent., died of tuberculosis or phthisis. Neumeister 
has put together a large number of cases both from the Wiirz- 
burg clinique and also from published papers, and gives a total 
of 438 cases, with 66, or 15 per cent., of deaths from tubercu- 
losis and phthisis, and 10, or 2'2 per cent., from acute tuber- 
culosis. Willemer states that, in the case of the knee-joint, 
1 per cent, of the patients die of tuberculosis during the first 
year of the disease, 6 per cent, during the second year, and 7 
to 8 per cent, during the third year. 

I believe that, apart from the fact that the cases in the 
above statistics were observed for a long time, the septic con- 
dition of the wounds in many cases aided the generalisation of 
the disease, but this is a point to which I shall again refer. 
Suffice it to say that, speaking roughly, something like 20 to 
30 per cent, of the patients suffering from strumous disease of 
the larger joints ultimately die of internal tuberculosis. Further, 
there is only a comparatively small percentage of the cases — 
Konig says about 21 per cent. — in which the joint disease is the 
only tubercular trouble. 



84 NATURE OF "STRUMOUS" JOINT DISEASES. 

Further proof that these diseases are of a tubercular nature, 
and the same as tubercular phthisis of the lungs, only modified 
by the situation and other conditions, is furnished by the fact 
that inoculation of animals with the morbid products from 
joints sets up tuberculosis in exactly the same manner as when 
material from the lungs is employed. I have, on many occa- 
sions, inoculated portions of synovial membrane and pus from 
strumous joints subcutaneously or into the anterior chamber of 
the eye in guinea-pigs and rabbits, and have invariably produced 
typical tuberculosis by this means. The same has been the 
experience of a number of other workers, though in a few cases 
negative results have been obtained. Much of the success 
depends on the care taken in introducing the material, more 
especially care that it shall keep its place, and not slip out 
again through the opening made, and also on the employment 
of a sufficient amount of the material. 

The last proof of the tubercular nature of these diseases to 
which I need refer is the fact that similar affections may be 
induced in animals by the introduction of tubercular material 
into bones and joints. Tubercular bone and joint affections 
have been produced by the sputum of phthisical patients, 
material from tubercular joints, the pus of chronic abscesses, 
&c. I have obtained absolute proof of their tubercular nature 
by setting up similar processes in animals by the injection of 
pure cultivations of tubercle bacilli derived from cases of 
human tuberculosis. Such cultivations, injected into the joints 
of rabbits and goats, set up typical strumous disease of these 
joints; injected into the blood vessels supplying the bones, 
cause tubercular deposits in the bone and disease of the neigh- 
bouring joints ; and injected into the epiphyses or medulla of 
bones, cause tubercular inflammation, with, in some cases, ex- 
pansion of the bone and new formation of bone from the 
periosteum, and, where the disease extended to the joints, the 
typical disease of the articulation. 



EXPERIMENTS WITH TUBERCLE BACILLI. 85 

I have already published an account of these experiments in 
The British Medical Journal, April 1891, and I need not do more 
here than mention one or two as examples. I may say that the 
experiments were performed with pure cultivations of tubercle 
bacilli from man mixed with sterilised water to form an 
emulsion. 

1. Injection into the knee-joint of a rabbit. — On January 11, 1888, 
a small quantity of the emulsion was injected into the right knee- 
joint of a rabbit. A week later there was marked swelling and heat 
of the knee-joint. The animal was killed on May 10, when the 
swelling of the knee was still considerable, though not so great as it 




Fig. 26. — Section of the knee-joint of a rabbit after injection of 
a pure cultivation of tubercle bacilli. (See Text.) 

had been. On post-mortem examination there was marked tuberculosis 
of the lungs, but in none of the other organs were tubercles visible to 
the naked eye. The right knee-joint was distended with cheesy 
material which had burst through the capsule and burrowed down 
the leg. In the joint there was a large quantity of pus, more 
especially above the patella and also behind the joint (see Fig 26). 

On making sections of the bones several small cheesy deposits were 
seen in the femur just above the epiphysial line, and in front there 
was a small hole in the shell of the bone containing cheesy material 
and communicating with the cavity of the joint on the one hand, and 
with these caseous deposits in the interior of the bone on the other. 
At one part of the epiphysis of the femur just beneath the articular 
cartilage the bone was yellow and dense. In the head of the tibia 



86 NATURE OF "STRUMOUS" JOINT DISEASES. 

there were two small yellow tubercles, and there was pus around the 
upper part of the shaft of the bone. The cartilage over the head 
of the tibia had disappeared and its place was taken by soft tissue. 

On microscopical examination of sections of the lower end of 
the femur the articular cartilage was seen to be almost entirely 
destroyed, the surface being covered with fibrous tubercular tissue 
caseating at the edge. Where cartilage was still present it was 
seen to be undergoing fibrillation and destruction. Over the centre 
of the end of the bone the tubercular tissue was penetrating into it, 
and there were one or two large tubercular nodules in the cancelli : 
the trabeculse were also thickened. Here and there were collections 
of epithelioid and small giant cells, but the chief form was tubercular 
infiltration. In the caseating patches numerous imperfectly stained 
and fragmentary tubercle bacilli could be made out. 

2. Injection into the nutrient artery of the tibia of a goat. — This is 
readily done by exposing the tibial artery just below the origin of 
the nutrient vessel, injecting upwards against the stream of blood 
and immediately ligaturing the artery below the nutrient vessel; the 
result is that the material injected is driven by the circulation into 
the nutrient artery and its branches. In this experiment the tibial 
artery was exposed at its upper part in a young goat, and about 
three minims of an emulsion of tubercle bacilli were injected in 
the manner above described. The wound was then closed and 
dressed aseptically. 

The animal was somewhat lame for a few days after the operation 
and then recovered, but after about three weeks the ankle joint, and 
somewhat later the metatarso-phalangeal joint began to swell and the 
animal limped very much, hardly putting the foot to the ground. 
The goat died fifty-one days after the operation. 

On examining the leg the soft tissues in the neighbourhood of the 
seat of operation were found to be very much thickened. The ankle 
joint, and more especially the metatarso-phalangeal joint, were very 
much swollen and larger than the corresponding joints on the 
other side, the thickening apparently affecting the bones as well as 
the soft tissues. No abscesses or cheesy patches were seen in the 
muscles or tissues of the leg. The inguinal glands on that side were 
much enlarged. The lungs were full of minute tubercles, for the 
most part transparent and not cheesy ; a few were seen in the liver 
but none in the other organs. 

This photograph (Fig. 27) is from a drawing made from the fresh 
section of the bones, and we see that there is a large number of 
cheesy deposits in the bones, more especially at the lower end of the 
tibia, and at the lower end of the metatarsal bone ; they were also 
very numerous, but more diffuse throughout the medulla of these bones 
and in the various tarsal bones. The synovial membrane in both 
joints, more especially in the metatarso-phalangeal joint, was much 
swollen and gelatinous. The deposits were not limited to the diaphysis 



EXPERIMENTS ON GOATS. 87 

of the tibia but occurred in the epiphysis, though they were not so 
numerous there. 

The following is the result of the microscopical examination : — 

In the lungs there were numerous tubercles which in many places 
had run together and contained numerous tubercle bacilli. 

In the medulla of the bone the deposits had evidently been formed 
in and afterwards around blood vessels, their centres were caseous, and 
their periphery composed of tubercular tissue. 

In the lower end of the tibia we see numerous caseating deposits 
in the bone, not only in the cancellous tissue, but also in the dense 
bone, in what is apparently newly formed bone, and in the periosteum. 




Fig. 27. — Section of the bones of the leg of a goat two months 
after injection of tubercle bacilli into the nutrient artery of the tibia. 
Shows numerous tubercular deposits in the various bones. (See 
Text.) 

As to the character of these deposits they are roundish or irregular 
collections of large cells undergoing caseation at the centre, but 
with no well formed giant cells. Many of the cancelli are filled 
with this tubercular tissue, and the trabecular around are eroded 
and often completely destroyed, several cancelli filled with this 
material communicating with each other. There is in places new 
formation of bone from the periosteum. In the epiphysis the deposits 
are not so numerous. The articular cartilage is almost entirely 
destroyed, and its place taken by tubercular tissue with a few small 



88 NATURE OF "STRUMOUS" JOINT DISEASES. 

giant cells. Here and there fragments of cartilage are found lying in 
this tissue. I think that the disease of the joint has been purely 
synovial in its origin, because in none of the specimens have I found 
any bone deposit breaking through the surface of the tibia, and the 
involvement of the epiphysis is comparatively slight. 

The os calcis also contained large numbers of tubercles, especially 
beneath the epiphysial line; there were also more giant cells here 
than I have seen elsewhere. The articular cartilage was almost 
entirely intact, except at one end where a deposit was seen sprouting 
out of the bone, destroying the cartilage over it,_ and spreading over 
the surface of and eroding the cartilage on each side. 

In the astragalus the deposits were fewer, but there were a good 
many in the cancelli just beneath the surface of the bone. The 
cartilage had been destroyed in parts, at some places apparently from 
the surface, at others by the tubercular deposits beneath it. The 
changes in connection with the destruction of the cartilage were 
precisely the same as those which occur in man. 

The lower end of the metatarsal bone showed also a number of 
tubercular deposits, very numerous indeed immediately above the 
epiphysial cartilage, and one or two very large ones in the epiphysis. 
The synovial membrane in this joint was also much thickened. 

Here then we have as the result of the injection of tubercle 
bacilli into the nutrient artery of the bone, and the deposition 
of these bacilli in various parts of the bone and periosteum, the 
formation of caseating tubercular deposits, destruction of the 
bone, new formation of bone, both in the interior and from the 
periosteum, thickening of the synovial membrane, and destruc- 
tion of the articular cartilages both from the surface and from 
soft osseous deposits bursting into the joints, in fact, all the 
changes characteristic of tubercular disease of bones and joints 
in man. And as in man in the specimens which I examined 
for bacilli, the organisms were few in number and imperfectly 
stained. 

3. Injection into the nutrient artery of the tibia, into the knee-joint, 
and into the metacarpal bone of a goat. — Small portions of a very 
dilute mixture of tubercle bacilli were injected into the nutrient artery 
of the right tibia in the usual manner, into the left knee-joint, and 
into the proximal end of the left metacarpal bone through a hole bored 
with a bradawl. As a result the knee and wrist joints became 
swollen, but there was no apparent disease in the right hind limb. 
As the goat was weak and ill, and apparently suffering pain, it was 
killed forty-seven days after the injection. 



EXPERIMENTAL DISEASE OF JOINTS. 



89 



On pod-movtem examination tubercles were seen in the lungs, 
spleen, and kidneys, all of small size. The right tibia showed nothing 
abnormal to the naked eye, and there was no swelling of the joints as 
in the previous case, hut the muscles around the seat of operation were 
much thickened and infiltrated with tubercles. 

There was great thickening of the synovial membrane of the left 
knee-joint, more especially in the neighbourhood of the crucial liga- 
ments, and the synovial membrane was covered with pendulous villous 
growths. These growths were most numerous where the synovial 
membrane joined the bone, and also between the condyles. There 
was no pus in the joint, and nothing abnormal seen in the bones (see 
Figs. 28 and 29). 

There was also great swelling of the left wrist-joint, and marked 
thickening of the synovial membrane. In the proximal end of the 




Fig. 28. — Section of knee-joint of goat, after injection of a very 
small quantity of a pure cultivation of tubercle bacilli. The villous 
condition of the synovial membrane is well seen. 

metacarpal bone there was a large cavity containing soft material, 
which communicated with the carpo-metacarpal joint. In this joint 
there were villous projections on the synovial membrane, similar to 
those in the knee, and when the joint was opened the appearance was 
exactly similar to that of a carious wrist-joint. The synovial mem- 
brane was thickened and highly vascular, and encroached on the 
articular cartilage and the bone, in fact, very little of the cartilage 
could be seen. The intercarpal articulation was also affected, but the 
radiocarpal joint was practically healthy. 

Microscopical examination of the various parts gave the following 
result :— In the lower end of the right tibia two tubercular deposits 



90 NATURE OF "STRUMOUS" JOINT DISEASES. 

were found presenting similar appearances to those in the former case. 
One of these was situated beneath the epiphysial cartilage, and the 
other somewhat higher up in the medulla. The articular cartilage 
was also destroyed at one part. Evidently very few bacilli had been 
arrested in the vessels in the bone, and disease was just commencing. 

The synovial membrane of the left knee-joint was greatly thickened, 
the new tissue being composed of young granulation tissue with tuber- 
cular infiltration, and a few small giant cells. There were no distinct 
tubercles, but there were here and there patches of caseating tissue 
exactly as in the wall of a chronic abscess. In some places the 
collections of epithelioid cells were more limited and almost formed 
definite tubercles. 

The sections of the synovial membrane of the wrist joint showed 




Fig. 29. — The same specimen as Fig. 28, seen from the front. 
The patella has been turned to one side. 

tubercular deposits scattered throughout the fibrous tissue, some of 
them with commencing caseation. This photograph (Fig. 30) is taken 
from a complete section of the wrist joint. Towards the posterior 
part of the metacarpal bone (on the right hand side) there is a 
tubercular deposit at the seat .of injection. This deposit has destroyed 
the bone and the articular cartilage over it, and has thus spread into 
the joint ; a number of the cancelli under the cartilage are also filled 
with the same material. On the anterior surface of the end of the 
metacarpal bone there is a considerable amount of new periosteal 
bone, and the bone around the deposit is much sclerosed. The 
synovial membrane in the articulation is much thickened and villous 
both in front and behind, and shows the presence of caseating patches. 



EXPERIMENTAL DISEASE OF JOINTS. 



91 



The adjacent carpal bone shows destruction of the articular cartilage 
at the lower and posterior part, and penetration of the tubercular 
tissue into the bone in this situation. There is much new periosteal 
bone in front, commencing destruction of the bone from the surface 
at the anterior and lower part, and great sclerosis in other places ; in 
the soft textures behind there is a commencing abscess. 

If, now, we examine the middle articulation, we find the same 
villous thickening of the synovial membrane, and commencing destruc- 
tion of the cartilage over the upper carpal bone, with sclerosis of the 
bone in the neighbourhood. 




Fig. 30. — Wrist joint of goat after injection of tubercle bacilli 
into the end of metacarpal bone. A deposit has formed and opened 
into the carpal joints, and has set up exactly the same sequence of 
events as is seen in Fig. 11. 



The upper articulation is comparatively healthy, but even there the 
synovial membrane is beginning to spread over the cartilage at the 
posterior part of the surface of the radius, and slight thickening of the 
synovial membrane is taking place. 

Compare this appearance with the section of the wrist joint (Fig. 
11) from the human subject, where the disease has also begun in the 
end of the metacarpal bone, and we find that the two appearances are 
essentially alike. 



92 NATURE OF "STRUMOUS" JOINT DISEASES. 

These experiments are sufficient to indicate the kind of 
results obtained, and to establish the causal connection between 
the tubercle bacillus and tubercular diseases of bones and joints, 
more especially when taken in connection with the work of 
other observers. I especially refer to the work done by Tricomi, 
Miiller, and Krause, the work of the latter completing the 
subject. Professor Krause repeated Schuller's experiments, who 
injured the joints of animals previously inoculated with tuber- 
lar material ; in Krause's work the animals were inoculated 
with pure cultivations of tubercle bacilli. Like other observers, 
he has found that severe injuries, such as dislocations, are not 
nearly so readily followed by tubercular joint disease, as slighter 
injuries, like sprains, and he also found that fractures of bones 
in tubercular animals heal without any trouble. Of joints 
which were dislocated or severely injured a few became 
tubercular, but of joints which were sprained, the majority 
ultimately showed evidences of disease. In the great majority 
of cases the form of the disease was a tubercular thickening of 
the synovial membrane resembling primary synovial disease in 
man. In a few cases he found isolated tubercles in the epiphyses, 
but in three he found larger caseating tubercular deposits. He 
also calls special attention to the difficulty of finding bacilli in 
these parts, although they were numerous in the tubercles in 
the internal organs. 



CHAPTER IX. 

ON THE ACCESSORY FACTORS WHICH COME INTO PLAY 
IN THE PRODUCTION OF TUBERCULAR DISEASES 
OF BONES AND JOINTS. 

Havixg thus studied the changes which occur in bones and 
joints in the course of tubercular disease in these parts, and 
having satisfied ourselves of their tubercular nature, more 
especially by the production of similar appearances by means 
of the tubercle bacillus, I propose now to refer very shortly to 
some of the conditions which come into play in the production 
of these diseases. Although there can no longer be any doubt 
that the tubercle bacillus is the ultimate cause of these affec- 
tions, and although without it they could not occur, the con- 
verse does not necessarily hold good, viz., that given the tubercle 
bacillus in the body tubercular disease must result. It is a fact 
to which I need not do more than allude that many persons are 
exposed to the possibility of tubercular infection without the 
development of tuberculosis, and yet we cannot doubt that in 
many of these individuals the tubercle bacilli have come in 
contact with various mucous membranes, or have been inhaled 
into the lungs. This fact proves not that tuberculosis is not a 
contagious disease, not that the tubercle bacillus is not the 
essential causal agent of tubercular diseases, but only that the 
bacillus cannot act except under favourable conditions — that, 
in fact, other factors must come into play to enable the bacillus 
to obtain a foothold and to grow in the animal body. One of 
the chief problems to which we must direct our attention in the 
future is the nature of these accessory factors, and there is no 
doubt that, as our knowledge with regard to them increases, 
so our power of dealing with these affections will become greater. 



94 CAUSATION OF THESE DISEASES. 

In the " Lectures on Suppuration and Septic Diseases " which 
I published some years ago, I attempted to point out the various 
conditions which came into play in the production of these 
affections, and to estimate their relative importance. Our 
knowledge with regard to the conditions under which the tubercle 
bacillus acts is, however, by no means so full as that with regard 
to the pyogenic organisms, and one reason for this deficiency is 
that it is difficult to carry on cultivations of these organisms 
outside the body, while their growth both outside and inside 
the animal body is very slow ; hence there are many difficulties 
in the way of the performance of similar experiments to those 
on septic infection, and the direct connection between cause 
and effect cannot be so readily traced. It is quite clear, how- 
ever, that similar factors must come into play, that conditions 
exist which favour or hinder the entrance of the parasite into 
the body, which enable it to obtain a foothold in certain parts, 
and which permit or encourage it to go on growing in these 
parts, and to cause the morbid changes characteristic of tuber- 
cular disease. 

The points of entrance of the tubercle bacillus are very 
various. I have already referred to instances in which the 
bacilli entered through wounds of the skin, and the characteristic 
lesions in such cases are the development of a sore at the point 
of entrance, followed by tubercular disease in the neighbouring 
lymphatic glands, and subsequently it may be in the tissues and 
organs of the body. This mode of entrance is, however, com- 
paratively rare. In order to inoculate the tubercular virus on 
animals with certainty it is necessary to form a pocket beneath 
the skin into which it is introduced, and in which it may lie 
at rest ; moisture and the possibility of remaining in the part 
for some time are essential for the groVth of the bacilli. If the 
tubercular virus is simply rubbed into scratches in the skin the 
blood containing the virus quickly dies, and in this way the 
growth of the bacillus is prevented, while even where there is 



POINTS OF ENTRANCE OF THE BACILLI. 95 

enough moisture the organisms are usually rubbed off or carried 
away before they have had time to obtain a footing in the 
wound. 

The most common point of entrance of these bacilli is, with- 
out doubt, the mucous surfaces of the body, more especially of 
the digestive and respiratory tracts. Thus, in children, one of 
the most frequent seats of tubercular disease is the lymphatic 
glands, chiefly the cervical, the mesenteric, and the bronchial 
glands. In the case of the cervical glands, infection usually 
occurs from the throat, from carious teeth, or from ear disease, 
eczema of the scalp, &c. In the case of carious teeth or otitis 
media, there are suppurating cavities through which the bacilli 
may enter, but in many instances there is no definite evidence 
of a primary lesion at the point of entrance, the only sign of 
disease being the enlarged glands in the neck, and yet in all 
probability the infective material has in most cases entered 
from the throat. In the same way it is not uncommon to find 
the mesenteric glands in children much diseased, although 
there is no tubercular ulceration of the intestine. Klebs states 
that the presence or absence of tubercular ulcers in the intes- 
tines of animals which are fed with tubercular material depends 
to a great extent on the size of the particles of the tubercular 
matter. He found that finely divided particles of tubercular 
material were absorbed without lodging and causing disease 
at their point of entrance in the intestinal mucous mem- 
brane, and were usually caught in the mesenteric glands, 
though in some cases they even passed them, and lodged in 
various internal organs. On the contrary, and this was also 
demonstrated by Chauveau, where the animals were fed with 
large and firm tubercular masses, such as cheesy glands or 
pieces of lung, intestinal ulceration occurred. In accordance 
with these results, it is only what we should expect that in 
many cases the point of entrance will not be evident, and this 
will more especially be the case in children, where the chief 
source of infection is probably the milk from tubercular cows. 



96 CAUSATION OF THESE DISEASES. 

And just as in the experimental, so in the natural infection, 
the virus may escape the glands, and produce the first symptoms 
of the disease in parts distant from the point of entrance. 

Another common seat of infection is the respiratory tract 
Apart from the local effects on the nasal passages, as manifested 
by the production of ulceration, &c. (grouped under the term 
scrofulous ozsena), it is not uncommon for the virus to be in- 
haled into the lungs, and either set up disease in the pulmonary 
alveoli in the first instance, or, as in the case of the intestine, 
pass through the alveolar epithelium and be carried to the 
bronchial glands, and set up disease there without any previous 
affection of the lung. Indeed, it seems very probable that 
in most cases the source of the joint infection is diseased 
bronchial glands. In order to reach the joint from these glands, 
the virus must of course be carried by the blood, and it has 
been demonstrated that the tubercular growth may destroy the 
wall of an artery or vein, and project into the lumen of the 
vessel, and thus furnish the conditions necessary for the entrance 
of the organisms into the blood current; or the virus may 
reach the blood from the lymph stream, more especially when 
the parasite has entered from the intestine, and has attacked the 
wall of the thoracic duct. When large quantities of the virus 
are poured into the blood in one or other of these ways, general 
tuberculosis results; but it is perhaps most common for the 
bacilli to enter the blood singly or in small numbers at a time, 
and then, unless they meet with conditions which favour their 
deposit in some suitable organ, they are quickly destroyed. 

It is possible, also, that in some cases infection occurs through 
the genital mucous membranes, especially where there is tuber- 
culosis of the prostate or of the uterus, infection resulting in 
the production of a sore at the point of entrance. This mode 
of infection is much more likely to occur in the female than in 
the male. 

Lastly, it is held by many that the disease is often hereditary 
— that is to say, that infection has occurred before birth, the 



TRANSMISSION FROM THE PARENTS. 97 

infective material having come from the male, being present in 
the semen, or from the female, chiefly through the placenta. 
In support of transmission from the male the following facts 
may be mentioned. 

Jani examined the generative organs of several individuals 
who had died of tubercular disease, and found tubercle bacilli 
in the seminal tubules in five cases, in the prostate in six, 
and in the Fallopian tubes twice, and in none of these cases 
was there any local disease. From these facts it has been con- 
cluded that, apart altogether from the presence of tubercular 
disease of the genital organs, tubercle bacilli may be present in 
the genital passages of tuberculous individuals, and thus gain 
access to the ovum. In connection with Jani's observations, 
which, however, are of doubtful accuracy, I may very briefly 
allude to some very interesting experiments which have been 
performed by Maffucci. Tubercle bacilli were injected into 
new laid eggs, which were then incubated. Eighteen eggs were 
inoculated, and at the same time an adult hen and a guinea- 
pig. The guinea-pig died after 40 days with tuberculosis of 
various internal organs, and the hen after 2 J months of internal 
tuberculosis, especially affecting the liver. Of the eighteen eggs, 
nine proved sterile, and in one the embryo died before full time, 
but no tubercle bacilli or tubercles were found in it. Eight 
chickens came out on the nineteenth day, and they were all 
small and delicate, but very active. One of these died after 
36 hours, but no tubercles were found in it, while the others 
lived for from 20 days to 4£ months, and in all of these, with 
one exception, tubercles and tubercle bacilli were found after 
death in the internal organs. The tubercular disease first 
appeared and was most advanced in the liver, and next in the 
lungs, and Maffucci came to the conclusion that infection 
occurred through the area vascularis, and that, therefore, the 
virus was carried, in the first instance, to the liver. 

With regard to Jani's statement as to the presence of tubercle 
bacilli in the seminal fluid of tubercular men, I may mention 

7 



98 CAUSATION OF THESE DISEASES. 

that Landouzy and Martin have injected the semen of 
tubercular rabbits into guinea-pigs, and have in this way 
produced tuberculosis ; while, on the other hand, Eohlff has 
failed to cause tuberculosis in rabbits by the injection of the 
semen of tubercular men into the anterior chamber of the 
eye. 

While these facts show that the possibility of the convey- 
ance of tubercle bacilli to the ovum by the semen cannot be 
absolutely denied, the probability of such an occurrence must 
be extremely slight. It is difficult, for one thing, to see how 
the bacilli get into the ovum, seeing that they are motionless ; 
one must almost suppose that they remain in the uterus, and 
grow in the decidual membranes, and thus enter the blood, but 
here we shoidd expect evidence of tubercular disease of the 
decidua or placenta. It is hardly conceivable that this can be 
a common, or, as is held by some, the most common mode of 
transmission of tubercular disease, especially when we bear in 
mind the greater frequency of tuberculosis in adult life, other- 
wise we must suppose that the bacilli are stored up in the body 
for years till some condition comes into play which enables 
them to develop. This is most unlikely, for we know by ex- 
periment that the most resistant spores cannot live in the healthy 
animal body longer than a few months. It is quite a different 
matter where the bacilli are enclosed in a caseous mass, which 
becomes encapsuled, for there the spores are protected by the 
caseous material from the action of the living cells, and juices 
of the body. 

The infection of the foetus from the side of the mother must 
also be equally rare, but might conceivably occur under two 
conditions, viz., where there is tuberculosis of the Fallopian 
tubes leading to infection of the ovum as it passes downwards, 
or where the placenta becomes the seat of tubercular disease. 
Numerous experiments have been made to ascertain whether 
after inoculation of a pregnant animal with an infective disease, 
the young become infected, and it has been found that, as a 



TRANSMISSION FROM THE PARENTS. 99 

rule, the young do not become affected. Unless the disease has 
first established itself in the placenta, or unless there has been 
rupture of placental vessels leading to the establishment of a 
communication between the maternal and the foetal circulation, 
organisms circulating in the blood in healthy placental vessels, 
are, as a rule, unable to pass into the foetal circulation, and 
this is apparently also the case in tuberculosis. Thus Toledo 
injected tubercle bacilli into the veins, pleural cavities, and 
subcutaneous tissues of pregnant guinea-pigs, but failed to 
find tubercles or tubercle bacilli in the young by any of the 
methods of investigation. 

Only one or two cases have been published either in animals 
or in man, where the young at the time of birth have shown 
evidences of tubercular disease, and, as in the experiments on 
animals, while women have died of acute tuberculosis during 
pregnancy no evidence of tuberculosis has been found in the 
foetus. We must, therefore, conclude that whether from the 
father or the mother transmission of the tubercular virus to the 
foetus must be an extremely rare occurrence, though it is possible 
that some cases of tuberculosis in infants may have originated 
in this way. 

The conditions which enable tubercle bacilli to obtain a foot- 
hold in the tissues, and which favour or hinder their growth, are 
very various, and are, as I have already said, but little under- 
stood. In my lectures on suppuration, I referred to one very 
important condition which held good in the case of all the 
organisms which I had investigated, viz., the number primarily 
introduced, and it will be remembered that I deduced certain 
very important laws from my experiments, one of them being 
that in animals not extremely susceptible to a disease, it was 
necessary to introduce a number of organisms at first in order 
to set it up, and another that the severity of the resulting 
disease varied directly with the number of organisms introduced 
in the first instance. I have not myself tested this matter in 



100 CAUSATION OF THESE DISEASES. 

the case of tubercle, but from experiments which have recently 
been made by others, it seems that the same laws hold good in 
this disease. Thus Gebhardt experimented with the milk of 
tubercular cows, and found that in cases where the original milk 
was virulent, it produced no effects whether injected subeutane- 
ously or into the peritoneal cavity when it was diluted forty 
times or more. In experiments on feeding animals with the 
sputum from phthisical patients, he found that infection did not 
occur when the sputum was diluted more than eight times, 
although the same sputum diluted 100,000 times caused infec- 
tion when injected subcutaneously. He obtained the same 
results when pure cultivations of tubercle bacilli were used, and 
he notes that the disease runs a much slower course when the 
number of bacilli originally introduced was very small. Wysso- 
kowitsch found that it was necessary to inject more than forty 
tubercle bacilli into the veins of rabbits in order to produce 
infection, and he makes the same observations as to the more, 
severe character of the disease, the greater the number of 
bacilli primarily introduced. 

The conditions which favour the deposit of these organisms 
in bones and joints are for the most part unknown, but experi- 
ments have shown that when large numbers of non-pathogenic 
organisms are injected into the blood they are rapidly deposited 
from the blood, and retained in the various organs, and one of 
their favourite seats is the medulla of bone, especially in the 
neighbourhood of the epiphysis. It has further been shown 
that the endothelium of the blood vessels takes up organisms 
floating in the blood, and this fact is of great interest in con- 
nection with the development of the tubercles from the vascular 
endothelium, to which I have previously referred. It is clear, 
however, that these facts alone are not sufficient to explain the 
affection of the joints, for we have to account for the limitation 
of the disease, in the first instance at any rate, to a single bone 
or joint. Konig supposes that many cases of joint disease are 



RELATION TO INJURY. 101 

due to embolism, the embolus being a plug of material contain- 
ing tubercle bacilli. This view, however, even if it were correct, 
and the evidence in favour of it is very slight, does not help us 
much, for it is difficult to see why the embolus should stop just 
where it usually does, and besides we can hardly suppose that 
only a single group of bacilli escaped into the blood vessels, 
and if there were more that one, why the disease should be 
only in one part. Besides, both from Jani's observations, if 
correct, and from experiments, it appears that a few bacilli may 
float about in the blood without causing local disease. Thus 
Steinheil produced tuberculosis in guinea-pigs by intraperitoneal 
injection of the expressed juice from the psoas muscles of 
patients who had died of phthisis, and Kastner has similarly 
caused tuberculosis in animals by the expressed muscle juice 
of cattle with advanced tuberculosis. So far as I can find, 
there was no evidence, of local disease of the muscles in 
these cases, and therefore we must assume that the bacilli 
were floating in the blood or juices of the body without 
causing local disease. It is quite clear from the above 
considerations that there must be local conditions at work as 
well. 

One very important local condition is a previous injury, and 
I have already referred to Krause's experiments, which clearly 
demonstrate this point. "We can readily understand that injury 
may act in various ways in determining the occurrence and 
localisation of infective diseases. One very obvious way in 
which injury may act is by leading to extravasation of blood, 
and, if bacilli are floating in the blood, to their deposit in the 
part. Injury also favours the growth of the extravasated 
bacilli, in that the result of the trauma is the production of 
changes in the part similar to those noticed in the early stage 
of inflammation, these changes being necessary for repair, and 
at the same time implying, in the first instance, a weakening of 
the resisting power of the tissues. Even where there is no 
extravasation, a slight injury may favour the deposit of bacilli 



102 CAUSATION OF THESE DISEASES. 

on account of the disturbance of the circulation, more especially 
the slowing, which results. As a rule, the cases where injury 
comes into play are usually attributed to a slight injury, such 
as a slight sprain or blow; the injuries are seldom said to 
have been severe. It is noteworthy that after severe injuries, 
such as fractures or amputations in tubercular subjects, tuber- 
cular disease does not occur at the seat of injury. I can recall 
more than one instance of a patient suffering from tubercular 
joint disease who sustained fractures, in one case of the shaft 
of a bone, the epiphysis of which was the seat of tubercular 
disease, and yet, although the injury occurred in the immediate 
neighbourhood of an extensive tubercular deposit, the fractured 
ends united without the development of any tubercular disease 
at the seat of injury. It is probable, as I pointed out in con- 
nection with septic diseases, that after a violent injury there 
is so much reparative material, and the repair is so vigorous, 
that the bacilli cannot obtain a foothold, while slight injuries 
only disturb the nutrition of the part, or at most set up the 
early stage of inflammation, and thus produce conditions 
favourable to the development of the parasite. 

We also not uncommonly notice that after tubercular joint 
disease has become quiescent, and apparently got well, it may 
recur as the result of a slight injury. In these cases it is 
probable that the bacilli or their spores have remained dormant 
in the interior of hard tubercular masses, and only wake up 
again when brought in contact with fluids and living tissue ; as 
the result of the injury these hard masses may be broken up 
and become infiltrated with the fluid poured out, and thus 
conditions may be furnished which enable the bacilli to grow 
again. 

That the commencement of tubercular diseases of bones and 
joints is often attributed to an injury is a fact so well known as 
not to require notice here, the point which has been so much 
disputed is whether the injury was in reality the starting-point 
of the disease, or whether the disease was not in existence 



RELATION TO INJURY. 103 

before, and the injury either only attracted attention to the 
part, or at most gave the disease, so to speak, a fillip. I have 
had the opportunity of examining by the microscope specimens 
from several cases where disease of bones was distinctly re- 
ferable to an injury, and I have found that the disease set up 
in these instances was undoubtedly tubercular. To mention 
two examples — (1) a female child, act. 5 years, with no phthisical 
family history, no evidence of previous tubercular disease, but 
with a strumous type of face, fell and struck the lower part of 
the sternum on a stone five weeks before admission. There 
had been no swelling or pain in the sternum before the accident. 
After the accident she began to complain of pain over the seat 
of injury, and a swelling formed, evidently affecting both the 
bone and the soft parts over it. On incising the swelling a 
drop or two of thick pus came out. The thickened soft parts 
were dissected away, and it was found that the bone had 
become extensively softened and infiltrated with caseous 
material. In this case there was no mistaking the clinical 
appearances as indicative of tubercular disease, and the micro- 
scopical examination confirmed the diagnosis. (2) A little 
girl, at. 2J years, of a healthy family, and herself previously 
healthy, was sitting on a doorstep five weeks before admission, 
and a blind man in passing trod on her ankle. As a result the 
ankle became painful and swollen, and these symptoms in- 
creased up to the time of admission. On examination of the 
ankle joint there was evidently tubercular disease of the 
synovial membrane, and the thickening was especially marked 
in front of the external malleolus. The intense pain caused by 
movement and by pushing up the heel, showed that the bone 
was also affected. I proceeded to perform arthrectomy by 
Konig's method, and after removing the whole of the anterior 
part of the synovial membrane, I found that the unossified 
layer of cartilage on the surface of the astragalus on the outer 
side had become detached, and examination of the bone beneath 
showed that there was a caseous deposit in the interior of the 



104 CAUSATION OF THESE DISEASES. 

bone which communicated with the synovial membrane at this 
point. I accordingly excised the astragalus, and found on 
sawing through the bone that there was extensive caseous 
infiltration of its substance, and a partially detached sequestrum 
in its interior. On microscopical examination many of the 
cancelli were seen to be filled with caseating tubercular tissue 
and tubercles, and there was sclerosis of the trabecules in the 
centre. I could mention several cases of a similar kind, but I 
may now allude to another proof that injury has a direct causal 
relation to tubercular joint disease, viz., that derived from 
statistical facts. I need not go into detail as to my statistics, 
but I may say that an investigation of the history of 293 cases 
of tubercular disease of the larger joints showed the following 
facts : — 

1. That where there is no history of injury, the proportion 
of cases in males as compared with females, commencing 
before and after 10 years of age, is practically the same, 
viz, 60:40. 

2. That the proportion of cases attributed to injury in males 
and females under 10 years of age is practically the same as 
where there is no history of injury, viz, 62 : 38, while 
after 10 years of age the proportion alters very much, viz, 
85-3 : 14-7. 

3. That of the cases in males attributed to injury, by far the 
largest proportion began after 10 years of age, viz, 284 before 
to 71-6 after, while the reverse is the case in females, viz, 384 
before to 41-6 after, numbers which do not at all correspond 
with the facts in cases where there was no history of 
injury. 

Now it is generally held that the liability of males to injury 
is greater in later life than that of females, while I think we 
may safely assume that before ten years of age their liability is 
the same. In correspondence with this the proportion of 
uninjured and injured females below ten years of age is about 
the same as that of males, while in later life there is an increase 



RELATION TO INJURY. 105 

after injury, of above 14 per cent, over that proportion in males, 
and a diminution of 14 per cent, in the case of women, i.e., 
instead of the proportions being equal there is an increase 
in males of 28 per cent, over females. Whatever be the 
exact meaning of the difference in the proportion between 
males and females at different periods of life, it is therefore 
clear from all these facts that injury plays a part which is 
not merely accidental, but that it is an active exciting cause 
of the disease. 

A further point which these statistics seem to indicate is 
that there is a local as well as a general susceptibility to injury, 
for it is not always in cases of disease of the most exposed 
joints that one most often gets a history of injury, and also 
the frequency with which the different joints are affected 
varies somewhat in males and females respectively. 

Lastly, it seemed from these statistics as if injury was not 
only an active agent in the production of these diseases but also 
as if it determined a graver form. The cases, in which injury was 
given as the cause were more serious than those where no cause 
was assigned as judged by the severity of the treatment re- 
quired for cure, by the results as regards complete recovery, 
and by the occurrence of suppuration. In the cases which 
followed injury, amputation, and excision were much more 
frequently required, suppuration more often occurred and the 
recoveries were fewer than in those which apparently com- 
menced spontaneously. 

It would be interesting if the above points should be 
confirmed by more extensive statistics to establish, if possible, 
some relation between the pathology of these diseases and the 
injury in order to account for the facts. It is conceivable 
that the depression of vitality of the tissues, as the result of 
the injury, may not only furnish a favourable nidus for the 
development of the tubercle bacilli, but may also leave a more 
or less lasting effect, enabling them not only to obtain a foot- 
hold but also to grow more luxuriantly. That this is not 



106 CAUSATION OF THESE DISEASES. 

altogether improbable is shown by the fact that the occurrence 
of an injury such as a twist of the joint during the course of 
the disease may render a trouble which was only progressing 
slowly a permanently active one. And it is also well known 
with regard to the use of violence in overcoming deformities, 
the result of disease, that this violence may again light up 
the process and lead to recurrence. It is conceivable also 
that injury may produce a graver disease by determining its 
outbreak in a special tissue, more especially in the bone. In 
the statistics to which I have referred, the facts as to the 
primary seat of the disease are very imperfect, because the 
treatment was not, as a rule, such as to elucidate this point, 
nor were special investigations made in cases where a decision 
was possible. Nevertheless it is striking that of the cases 
where there was little doubt that the bone was primarily 
affected a considerable excess occurred in those where there was 
also a history of injury. Thus of 301 cases the bone was 
undoubtedly primarily affected in 94 or 31 '2 per cent. Of the 
193 uninjured cases the bone was the primary seat of disease 
in 53 or 2 7 '4 per cent. ; in 108 traumatic cases the bone was 
primarily affected in 41 or 37'9, an excess of primary bone 
disease of 10-5 per cent. It seems to me that injury would 
most probably tell more on bone than on the soft parts, for 
the latter slide before a blow, while the bone receives the full 
force of it, and in sprains the part of the ligaments on which 
the strain chiefly tells is probably the attachment of the liga- 
ment to the bone. Again in the ends of bones the formative 
process is, of course, most active during the period of growth 
and disturbances of the circulation such as are produced by 
injury may readily act as the starting point of the disease, 
enabling the virus to gain a foothold in the part, which it does 
the more easily as the tissue is in a young and transient 
state. 

Apart from the question of injury there is some local condi- 
tion which is not very clear which influences the outbreak of 



FREQUENCY IN DIFFERENT JOINTS. 107 

the disease more frequently in one bone or joint than in another. 
Varying estimates have been given by different writers as to 
the relative frequency with which the individual bones and 
joints are affected, the variations being due partly to the age of 
the patients examined, and partly to whether they were in- or 
out-patients. I need not go into all these statistics, but I 
think the following table gives a fair estimate of the distribu- 
tion of the disease including all ages. It has been obtained by 
adding together the figures given by Jaffe, Schmalfuss, Billroth 
and Menzel, and 602 cases of my own, partly composed of the 
cases previously referred to, and partly of cases which have 
occurred as in- and out-patients in the practice of Mr. Stanley 
Boyd and myself at Paddington Green. The table clearly 
shows the existence of some local predisposition which we 
cannot as yet define, which renders one part more liable to be 
attacked than another. 



Spine, 


23-2 per 


Knee-joint, 


16-5 


Hip-joint, 


14-6 


Tarsus and ankle-joint, 


14-4 


Elbow-joint, 


6-3 


Wrist and hand, 


6 


Skull and face, . 


5-5 


Sternum, clavicle, and ribs, 


5-2 


Pelvis, .... 


3-5 


Femur, tibia, and fibula, . 


3-5 


Shoulder, . 


1-5 


Scapula, ulna, and radius, . 


1 


Humerus, ... 


0-8 


Patella, . . . . . 


o-i 



cent. 



Another local factor which in all probability influences the 
occurrence of the disease, and which certainly favours its spread 
is chronic inflammation. It is, of course, almost impossible to 



108 CAUSATION OF THESE DISEASES. 

point to any individual case and say that that case illustrates 
the occurrence of tubercular disease in a part which was pre- 
viously the seat of some chronic inflammatory trouble, for the 
natural reply is how do you know that the chronic inflam- 
matory trouble was not tubercular from the first ? In the case 
of tubercular cervical glands, however, we see that these often 
become enlarged as the result of what I think we must admit 
to be simple irritation from the mouth, head, or neighbouring 
parts, and that the glands so enlarged may ultimately become 
the seat of tubercular disease, and we get this history so often 
that there seems little reason to doubt that the previous in- 
flammatory enlargement has predisposed the part to the sub- 
sequent infection. Further, when tubercular disease has com- 
menced chronic inflammation is set up in the vicinity, and the 
tubercular growth spreads in the directions in which the chronic 
inflammation is most marked. Again it seems to me that the 
best explanation of the good results which follow aseptic 
incisions into tubercular joints, where the synovial membrane 
is much thickened, and where none of the disease is removed, 
and also the good results of partial arthrectomies where only 
part of the disease is removed is that the operative procedures 
have relieved or diminished the chronic inflammation around 
the tubercular area, and have thus checked the progress of the 
disease. Among the cases which form my statistics there 
were 19 cases of disease of the knee-joint without suppura- 
tion, in which simple incisions were made through the thick- 
ened synovial membrane into the joint, none of the tissue being 
removed, and yet 15 of these showed marked improvement 
as the result of this treatment. This method of treatment was 
commenced on the principle of relief of tension before the 
tubercular nature of these diseases was understood, and it is 
difficult to find any other explanation of the results than by 
supposing that the relief of tension led to cessation of the 
chronic inflammatory condition, and thus interfered with the 
growth of the bacilli. 



INFLUENCE OF SEPSIS. 109 

Other factors which aid the extension of tubercular disease, 
probably by keeping up a state of chronic inflammation in the 
part, are movement and the pressure of diseased surfaces 
against each other, whether from the weight of the body or 
from the tonic contraction of the muscles surrounding the 
joint. 

The presence of pyogenic organisms along with tubercle 
bacilli is a very potent factor in aiding the spread of tuber- 
cular disease. The tubercle bacillus evidently finds in many 
individuals great difficulty in obtaining and maintaining a 
foothold, and anything which depresses the vitality of the 
tissues will, without doubt, aid its progress. We have seen 
how the disease frequently assumes increased activity, or 
springs again into life after an injury, one effect of the injury 
being to depress the vitality of the part. It may also be often 
noticed that, while the general health of the patient remains 
good, the local affection is very chronic and makes but little 
progress, while if the health becomes lowered, the local disease 
assumes a more rapid course, and suppuration often occurs. 
And so we might instance a number of facts in support of 
the statement, that anything which interferes with the healthy 
state of the part and diminishes its vitality, leads to more rapid 
extension of the tubercular disease. Now, one of the most 
powerful depressing agents, both local and general, is a septic 
state of a wound. The septic organisms, by virtue of the 
products of their growth, interfere seriously with the vitality 
of the tissues, and render them less able to resist the invasion 
of other parasites, while these products, being absorbed, still 
further favour the local and general spread of the disease by 
their effects on the system generally. Thus, apart from the 
suppuration, profuse discharge, hectic fever, &c, which are the 
results of sepsis, the local tubercular disease makes more rapid 
progress when there is a septic condition of the diseased part 
than when the skin is unbroken and the tissues are not 
depressed from this cause. 



110 CAUSATION OF THESE DISEASES. 

The influence of sepsis in keeping up the tubercular process 
is well seen when we compare the result of the aseptic drainage 
of abscesses, connected with tubercular disease of bones and 
joints, with that obtained in septic cases. Taking the cases of 
spinal abscess in the foregoing statistics, we have a record of 58 
cases treated by drainage, of which 49 remained aseptic from 
first to last, while 9 became septic. Of these 49 cases, at the 
last note 38 or 77'5 per cent, had healed, 5 were improving 
but had not yet healed, 1 was still in hospital, and 5 had died ; 
while of the 9 septic cases, none had healed and 3 had died. 
I need not go into the statistics with regard to all the other 
bones, but the result is very similar ; in the case of the hip- 
joint, however, I may mention that we had 25 cases of suppura- 
tion connected with this joint treated to the end by aseptic 
incision and drainage, and of these, 72 per cent, were cured, 24 
per cent, were incomplete, some doing well some not, and 4 per 
cent, had died. Contrast this result with Mr. Howard Marsh's 
table of 260 septic hip-joint cases, of which 32-8 per cent, 
were known to be cured, 237 per cent, were incomplete, and 
335 per cent, had died. Contrast also our results in spinal 
abscesses, treated aseptically, with the universal opinion of 
surgeons before the antiseptic era, that these abscesses but 
rarely healed after they burst or were opened. The serious 
interference with healing, caused by the presence of pyogenic 
organisms, would also be still more evident if we contrasted 
the severity of the treatment required for cure in cases with 
aseptic and with septic sinuses respectively. I need, however, 
only mention here that in 105 cases of disease of tjie larger 
joints with aseptic sinuses, excision or amputation was only 
required in 37 or 35'2 per cent., while in a similar number of 
cases with septic sinuses, these operations were necessary in 
69 or 6 5 p 7 per cent. 

It is true that in these septic cases the bad results as regards 
life may be due directly to the pyogenic organisms setting up 
and keeping up suppuration and septic disease, quite apart from 



INFLUENCE OF SEPSIS. Ill 

any extension of the tubercular process, but it cannot be the 
presence of the septic organisms alone which prevents the 
wounds from healing, for we know that suppurating wounds 
in healthy tissues heal readily enough in spite of the sepsis ; 
it must be that the septic condition, superadded to the tuber- 
cular disease, prevents the latter from being destroyed by 
the tissues, and not only so, but actually aids the growth of the 
tubercle bacilli. 

I have also found in experiments that the disease is more 
rapid in animals where tubercular sputum (i.e., septic tuber- 
cular matter) is used, than when a small number of tubercle 
bacilli is injected. This influence of sepsis is also, no doubt, 
the main explanation why, as a matter of experience, partial 
operations, such as gouging or scraping away the diseased parts, 
are not looked on with favour, for the septic condition, if not 
eradicated at the time of the operation, rapidly lowers the 
vitality of the part which may have been left free from 
disease, and thus re-infection soon occurs from the diseased 
portions left behind. 

It has also been pointed out by Konig and others that 
tubercular meningitis is more frequent in septic than in aseptic 
cases ; thus, of sixteen cases of tubercular meningitis which 
occurred in Konig's practice eleven affected septic cases. In 
former times, too, phthisis seems to have been more common 
after these joint diseases than it is now, and this fact I am 
also inclined to refer to some extent to the septic condition of 
the wound. Thus Billroth gives the proportion of deaths from 
phthisis and general tuberculosis in cases of tubercular joint 
disease as 27 per cent., while Konig, working more antiseptically, 
gives it as 16 per cent. In our own cases the mortality from 
tuberculosis is very much less, but this may be to some extent 
due to the shorter length of time that the patients were under 
observation. Of our 386 patients, only 17, or 44 per cent., 
are known to have died of tubercular disease, including 
tubercular meningitis, while only 42, or 10-8 per cent., are 



112 



CAUSATION OF THESE DISEASES. 



known to have suffered from phthisis or tuberculosis else- 
where. 

Passing now to factors which act in a general rather than 
a local manner, the first which we have to note is the question 
of age. The frequency with which the disease commences at 



Table showing percentage proportion of cases of bone and joint 
disease, commencing in each quinquennial period, and in 
males and females respectively. 



Age. 


Total. 


Males. 


Females. 


1- 5 


232 


14-3 


8-8 


6-10 


16 


9-5 


6-5 


11-15 


14-6 


9-5 


5 


16-20 


15 


9-5 


5-8 


21-25 


8-5 


6-3 


2 


26-30 


8-8 


5-3 


3-3 


31-35 


4 


4 




36-40 


3 


2-4 


•8 


41-45 


2 


2 




46-50 


2 


1-8 


•4 


Above 50 


2 


1 


1 



various periods of life differs greatly in the case of different 
joints, but as a whole it is most frequent in childhood. This is 
well seen in the accompanying table, where we have first the 
percentage of the total cases, commencing in each quinquennial 
period up to 50 years of age, and secondly, the percentage of 
males and females. Thus, of every 100 cases admitted, 14 - 3 
were males in which the disease commenced before the end of 
the fifth year, &c. We thus see that the disease commences 



RELATION TO AGE. 113 

most frequently, both in males and females, during the 
first quinquennial period, and steadily decreases as age 
advances. 

This table does not, however, represent accurately the risk of 
the occurrence of these diseases at different ages, for it may 
quite well be that a greater number of cases occur during the 
first five years of life, because a greater number of persons 
are alive at that age than at any other. In fact, it may be that 
the percentage proportion of individuals attacked during the 
first five years of life is actually less than that of those attacked 
say between 15 and 20 years of age, when considered in 
relation to the number of persons alive at these ages, and thus 
although more cases commence in the first quinquennial period, 
the actual probability of the occurrence of tubercular joint 
disease may be greater in later life. Investigations of this kind 
have been made with regard to phthisis, and have led to the 
surprising result that in Copenhagen, Sweden, and various 
German cities, the danger of phthisis in any given individual 
constantly increases with advancing age, and that in advanced 
life a larger proportion of the individuals alive at that age die 
of phthisis than at the period of life in which it has been 
supposed to be most frequent (15 to 30 years). Fassbender 
has applied a similar mode of investigation to cases of tuber- 
cular disease of bones and joints, and found that although the 
results did not correspond to those obtained in phthisis, yet the 
proportion of adults and old people affected was in reality 
greater than seemed to be the case. 

Employing the German statistics of the proportion of persons 
per thousand alive at different ages, I have calculated the real 
frequency of the disease in my cases, and in the following table 
we have the ratio per thousand (expressed as a percentage) of 
my cases of disease of the seven larger joints beginning in each 
quinquennial period, to the persons alive at that quinquennial 
period. In the first column I give the apparent frequency, in 
the second the real frequency as calculated from my own 



114 



CAUSATION OF THESE DISEASES. 



cases, and in the last the real frequency as calculated by 
Fassbender. 



Age. 


Apparent 
frequency. 


Real 

frequency. 

(mine.) 


Real 

frequency. 

(Fassbender.) 


1- 5 


232 


167 


108 


6-10 


153 


134 


145 


11-15 


150 


145 


113 


16-20 


153 


164 


157 


21-25 


85 


98 


77 


26-30 


88 


120 


109 


31-35 


41 


60 


76 


36-40 


30 


48 


106 


41-45 


20 


36 


66 


46-50 


20 


42 


85 


In decades. 
50-60 


14 


17 


About 60 


60-70 








About 42 


70-80 


7 


33 


About 21 



From this table it will be seen that my results, in the main, 
confirm Fassbender's conclusion that the real frequency of 
these diseases is greater in advanced life than has been 
supposed, but that it is much less than in youth. In my list 
the disease commences most frequently between 1 and 5 
years of age, then declines and rises again between 15 and 20, 
and then again steadily declines, with the exception of slight 
rises between 25 and 30 and between 45 and 50 ; the accuracy 
of the latter numbers is, however, very doubtful, because I had 
only a few cases in my list which commenced at that age. My 
results agree with Fassbender's in the rise between 15 and 20 



RELATION TO AGE. 



115 



years of age, but disagree somewhat in the frequency between 1 
and 5 and in later life. 

Great differences exist as to the period of life at which the 
disease commences in different joints as is evident from the 
following table in which I have indicated the percentage pro- 



Table showing percentage proportion of total cases commencing 
in each decade affecting each joint. Thus, of 149 cases 
commencing during the first decade 30 - 2 per cent, were cases 
of hip disease, &c. 



Decades. 


I. 


II. 


III. 


IV. 


V. 


Hip, 


30'2 


20-3 


4-8 




12-5 




29-5 


22-8 


18-2 


36-6 


6-2 




5-4 


5-9 


3-6 


3-3 


12-5 




4-6 


5-9 


8-4 


3-3 


187 






1-6 


4-8 






Elbow, 


67 


9-2 


6 


13-3 


18-7 


Wrist, 


•6 


8-4 


15-8 


13-3 


6-2 




1-5 


4-2 


2-4 






Ribs, 






1-2 


10 


12-5 






2-6 


2-4 


2-4 


3-3 




Odd bones, ... 


6-7 


3-2 


3-6 






Spine, .... . . . 


12 


15-2 


28 


20 


12-5 



portion of cases of disease in each of the seven larger joints, 
commencing in each decade. 

Thus, of 149 cases of tubercular bone and joint disease (in- 
cluding ribs, fingers, &c), which commenced during the first 
decade, 30 - 2 per cent, were cases of hip-joint disease, 29-5 per 
cent, were cases of disease of the knee-joint, and so on. Now 
from this table we see that of the cases commencing in the 



116 CAUSATION OF THESE DISEASES. 

first decade the highest point is occupied by the hip-joint ; in 
the second decade by the knee-joint; in the third decade by 
the spine ; in the fourth decade by the knee ; and in the fifth 
decade by the tarsus and elbow. As regards the various joints, 
we see from the former chart that hip-joint disease commences 
by far most often during the first decade, and its frequency 
diminishes very rapidly. The knee-joint is also most frequently 
attacked during the first decade, but the fall in frequency 
is by no means so rapid, and the cases are fairly numerous 
even above fifty years of age. Ankle-joint disease also com- 
mences slightly more frequently before ten years of age, but 
also very frequently in the second, and to a less extent, in the 
third decade. Disease of the tarsus is much more evenly dis- 
tributed over the first three decades. There were no cases of 
disease of the shoulder-joint during the first decade, and they 
were most frequent in the third. The elbow-joint was rather 
more frequently affected in the second than in the first decade. 
Disease of the wrist-joint was most common in the third decade, 
and very rarely commenced in the first. Disease of the fingers 
was most common in the second, of the ribs in the fourth, and 
of the os calcis in the fourth. Disease of the spine was most 
common in this list in the third decade. 

From the above list we would arrange the various bones and 
joints in the following order of frequency of occurrence, from 
youth upwards : — hip ; knee ; ankle and elbow ; tarsus ; fingers ; 
spine; shoulder; wrist; ribs. In order of frequency of occurrence 
during the first decade we have: — hip; knee; spine; elbow; ankle; 
tarsus; fingers; wrist. "While this list gives a fairly accurate idea 
of the state of matters, there is one glaring discrepancy from what 
we know to be the case, viz., with regard to the spine. Spinal 
disease is in reality by far the most frequent tubercular disease 
of bone during the first decade of life. Thus, taking the surgical 
out-patients seen at Paddington Green up to June 1888, we 
have a total of 2997 at or below 10 years of age, and of these 
190 were cases of tubercular disease of bones and joints. Of 



RELATION TO AGE. 117 

these 190 cases 78 were cases of spinal disease, 44 of hip-joint 
disease, 24 of knee-joint disease, 13 elbow-joint, 3 of tarsus, 1 of 
ankle, 2 of shoulder, 2 of wrist, 8 of fingers, 1 of ribs, and 14 of 
various other bones. This gives us the following order of 
frequency below 10 years of age, which we may contrast with 
the order in in-patients : — 



Out-Patient List. 


In-Patient List. 


Spine. 


Hip. 


Hip. 


Knee. 


Knee. 


Spine. 


Elbow. 


Elbow. 


Fingers. 


Ankle. 


Tarsus. 


Tarsus, excluding os calcis. 


Shoulder. \ 


Os calcis. 


Wrist. / 


Fingers. 


Ankle. 


Wrist. 


Eib. 


Eibs. 



Thus, there is no very marked discrepancy except in the case of 
the spine, and this discrepancy is quite in accordance with what 
we know of the course of spinal disease in children and adults. 
Cases of spinal disease have only rarely been admitted, unless 
when abscess was present, and we know that suppuration in 
connection with spinal disease is not common in children, but 
is very common in the second and especially in the third decade. 
Thus, out of 60 cases of disease of the spine, which I saw myself 
as out-patients, I only found it necessary to admit 9, while of 
29 cases of hip-joint disease I admitted 10, and of 13 cases of 
knee-joint disease I admitted 7. Thus, the small number of 
spinal cases treated as in-patients during this decade, and the 
smaller excess of hip-joint cases over knee-joint cases in in- 
than in out-patient practice is readily explained. These results 
correspond very closely with those given by other writers. 

I may mention another point with regard to age, viz., that 
several authors — Muller, for example — have held that tubercular 
disease of the spine does not occur before the third year of life. 



118 CAUSATION OF THESE DISEASES. 

In our list of in-patients, however, we have one case which 
began at 3 months, and 3 others during the first year of life. 
Of the out-patients 4 were only a few months old when they 
came under observation, 3 were a year old, 9 in the second year, 
and 6 two years old. It is certainly the fact that tubercular 
disease of any kind is rare during the first year of life. Thus, 
Frobelius, with a material of over 91,000 children in a Foundling 
Hospital, found that the deaths from tuberculosis in children 
under one year of age were 0'4 per cent, of all the children, and 
2-2 per cent, of all that died. He concludes that tuberculosis 
is a rare disease during the first year of life, that sex has no 
influence over the disease at this age, that overcrowding and 
bad ventilation predispose to it, that inhalation tuberculosis is 
the most frequent form, and that the disease, though sometimes 
localised in one organ, usually becomes rapidly general. 

In my statistics I have also found that age not only affects 
the commencement of these affections, but also influences their 
severity, a fact long known and accepted. That this should be 
so is not a matter of surprise, for the activity of the vital pro- 
cesses, and the resisting power of the body, diminish with age. 
I need not go into all the points, which show the increasing 
severity of these affections with advancing age, but I may refer 
to one, viz., the frequency of suppuration. Taking only the 
cases admitted to the hospital, I find that during the first 
decade 66 per cent, ultimately suppurated ; during the second 
decade 74-5 per cent.; and during the third decade 86'2 per 
cent. No doubt this does not give an absolutely accurate idea 
of the relative frequency of suppuration, for of out-patients 
during the first decade really only a small number suppurated, 
and the above figures are, no doubt, in all cases too high, but 
more especially during the first decade. This increasing severity 
of the disease in joint cases as age advances is also, no doubt, to 
a large extent due to the increasing proportion of cases in which 
the disease commences primarily in the bone, and also the 
greater frequency of sequestra over soft caseating deposits. 



RELATION TO SEX. 



119 



Sex is also another important factor in the production of 
these diseases. Thus in our 386 patients under treatment in 
hospital, 251, or 65 per cent., were males, and 135, or 35 per 
cent., were females. This is a fact which is noted by most 
authors, although the relative percentages of the two sexes may 
be somewhat differently given ; in the case of the spine, the 
statements are the most contradictory. The relation of the sexes 
varies at different ages, as is shown in the former table (p. 112). 
Thus, of the total number of cases admitted, 14-3 per cent, were 
males, and 8 - 8 per cent, were females, at or below five years 
of age, &c. The predisposition of the sexes to disease also varies 
according to the joint in question, as seen in this chart, where 
we see that the numbers most nearly approach one another in 
the case of the knee-joint, 576 per cent, being male, and 424 
per cent, female, and are furthest apart in the case of the tarsus, 
where 85-8 per cent, are males, and 14-2 per cent, females. 
(The cases of shoulder-joint disease were too few to be of value). 



Percentage Relations of Males and Females in each Joint. 





Hip. 


Knee. 


Ankle. 


Tarsus. 


Shoulder. 


Elbow. 


Wrist. 


Males, . 


597 


57-6 


81-9 


85-8 


50 


74-3 


75-9 


Females, . 


40-3 


42-4 


18-1 


14-2 


50 


25-7 


24-1 



Further, it appears that the disease is more grave in males 
than in females, and that to some extent independently of age 
or injury, whether we test the matter by the severity of the 
measures required for cure, by the results of treatment, or by 
the frequency of suppuration. This is a point which is not 
referred to, so far as I have seen, by other writers, although 
some, such as Albrecht, give tables of the methods of treatment 
employed in the two sexes, and these tables show a larger pro- 



120 CAUSATION OF THESE DISEASES. 

portion of cases treated by the expectant method, and a smaller 
proportion of cases treated by excision and amputation in females 
than in males. This fact would, however, correspond with the 
less susceptibility of females to the disease ; diseases when they 
occur in individuals but little susceptible to them, being as a 
rule milder than when they attack the highly susceptible. 

Among other general predisposing conditions are those which 
have led to the belief in the heredity of tubercular disease. As 
I have previously said, it must, in my opinion, be extremely 
rare that the disease itself is inherited, nevertheless, it is 
more apt to occur, and is more severe in families where there is 
a tendency to the disease as indicated by its occurrence among 
several members, this tendency not being altogether accounted 
for by increased opportunity of infection. It is, however, not 
the disease itself, but the peculiar collection of conditions 
which renders the patient liable, to infection, which is trans- 
missible to the offspring. Where these conditions are present 
and fully developed the bacilli naturally get an easier and a 
firmer foothold, and grow more luxuriantly than in other in- 
dividuals, and the disease is thus correspondingly graver. 
Scrofulous children are more predisposed to the occurrence of 
tuberculosis because the tissues, apart from their peculiar tend- 
ency, are less strong and active, seeing that the children are 
usually delicate, and are thus more confined to the house and 
to badly ventilated rooms, &c, than healthy children. These 
or similar conditions of the tissues may also be induced by 
poverty with its attendant evils. The bad hygienic conditions 
under which poor children live, their confinement to badly 
ventilated rooms, or to the foul alleys of large towns, the 
deficient quantity and bad quality of their food, &c, are all 
factors which deprave the constitution and render it less able 
to resist the attacks of any parasitic disease. There is also 
some reason for supposing that apart from the poor quality and 
deficient quantity of the food, its chemical constitution is of 
some importance, and notably that an excess of vegetable food 



RELATION TO FOOD. 121 

is bad. As regards food, Bidder, in speaking of the treatment 
of these diseases, lays great stress on the avoidance of sub- 
stances rich in potash and also of starchy materials, and strongly 
advises the employment of albuminous foods rich in soda and 
fat. A probable confirmation of this view is the noteworthy 
fact that tuberculosis is, as a rule, very common in herbivorous 
animals, and can usually be readily induced in them, while on 
the other hand, it seldom occurs in the carnivora. Man who 
employs a mixed diet stands midway between these two groups 
in his susceptibility to this disease, tuberculosis being more 
often local and less virulent than in the herbivora, while it is 
much more frequent and destructive than in the carnivora. 
In this way also Bidder explains the much greater frequency 
of tubercular diseases in the western part of Germany than in 
the eastern, although the density of the population is greater 
in the latter ; it appears that the inhabitants of Eastern 
Germany employ less vegetable diet than in the west, and eat 
large quantities of salt meat. 



CHAPTEK X. 

ON THE CUBABILITY OF TUBERCULOSIS AND THE 
CAUSES WHICH INTERFERE WITH RECOVERY. 

Before going on to the discussion of the various methods of 
treatment, we must inquire what the natural tendency of tuber- 
cular disease is as regards recovery, in what way spontaneous 
cure takes place, and what factors tend to oppose its occurrence. 
The relation of the tubercle bacillus to the living tissues 
varies much in different species of animals. In some, such 
as guinea-pigs, the tissues are invariably overcome in the 
struggle with the parasite, and the result of the subcutaneous 
inoculation of even a few tubercle bacilli into these animals 
practically always leads to the production of a local tuber- 
cular lesion, subsequent dissemination of the disease over the 
body, and the death of the animal. On the other hand, in 
the dog, for example, the tissues are much more powerful 
in their action on the bacilli, and unless the latter are intro- 
duced into the body under exceptionally favourable circum- 
stances, they die out, and the animal remains well. Thus, 
in the case of dogs, large numbers of bacilli must be used, 
whether for inhalation or injection; small numbers usually 
produce no effect, and, further, there is a very strong tendency 
to localisation of the lesions, as shown, for example, by 
Tappeiner's inhalation experiments, in which large quantities 
of infective material were used, and the tubercles remained 
limited to the lungs in the great majority of the cases. In 
man the conditions are somewhat analogous to those in the 
dog ; the tubercle bacillus in many cases makes headway only 
with great difficulty, the disease often remains localised for a 
long time or altogether, and there is a constant tendency under 



RETROGRESSIVE CHANGES. 123 

favourable circumstances for the process to come to a stand- 
still ; in fact, in many cases comparatively little is required to 
turn the scale against the parasite. Hence in the case of man 
there is an increasing tendency to believe in the possibility of 
recovery from tubercular lesions. 

Eecovery may take place either after the formation of a 
communication between the tubercular deposit and the ex- 
terior, or without any such communication. Where a tuber- 
cular deposit has opened externally, a considerable portion is 
evacuated, and when healing occurs, only a fibrous induration, 
with sometimes a little caseous material in it, is left to mark 
the seat of the original disease. Where no communication has 
formed externally, the retrogressive changes are of various 
kinds, depending on the extent and character of the lesion, 
more especially on whether the tubercles are discrete or agglom- 
erated in masses, and on whether caseation has occurred 
or not. Where the tubercles are discrete and not caseous at 
the time that the bacilli cease to act, the probability is that 
the tubercle will disappear and leave practically no trace be- 
hind, the amount of fibrous tissue resulting from the organisation 
of each single tubercle being too small to be noticeable. How 
this exactly takes place is not quite clear. In specimens from 
cases of synovial disease treated by tuberculin, in which retro- 
gression was occurring, I found apparently two sets of changes. 
In the one the epithelioid cells of tubercle seemed to disappear, 
probably by a process of atrophy, their place being taken by 
smaller cells, which developed into fibrous tissue ; this seemed 
to be the most common appearance. In other cases the 
epithelioid cells themselves became spindle-shaped, and de- 
veloped directly into fibrous tissue. Similar appearances may 
also be found in synovial membrane, in which improvement is 
taking place quite apart from the use of tuberculin, but I 
think the first form is the most common — viz., that the epi- 
thelioid cells atrophy and disappear, and a small fibrous scar 
is formed from the cells outside the tubercle. Under these 



124 CURABILITY OF TUBERCULOSIS. 

circumstances a true cure results. Where recovery takes place 
in a case of early synovial disease where the tubercles are still 
discrete and not very numerous, the process is no doubt of the 
nature above described, and the amount of newly formed 
fibrous tissue being extremely small, and in patches rather 
than continuous, there is little or no ultimate limitation of 
movement. Cases of tubercular synovial disease recovering 
with complete restoration of movement, are of course rare, but 
I have had two or three where the treatment was begun quite 
early, and persevered in for a long time, with complete re- 
covery as regards appearance and function, and no apparent 
proneness to relapse. As a rule, however, somewhere or other 
the tubercular tissue is massed together, and then, if complete 
recovery of the tuberculosis do take place, a greater or less 
amount of stiffness is left behind, owing to the larger amount 
of new fibrous tissue formed. 

Where the tubercular masses are larger, or where caseation has 
occurred, at any rate to a marked degree, complete cure seldom 
occurs, although the disease not uncommonly becomes quiescent 
In such a case, a large amount of fibrous tissue is formed around 
the mass, and, no doubt, a considerable amount of the tubercular 
material disappears, or is converted into fibrous tissue, but where 
the mass of tubercular tissue is large, remains of tubercles or 
portions of caseous material, often infiltrated with calcareous 
salts, to such an extent as to form small calcareous nodules, are 
generally found towards the centre of the new fibrous tissue. 
These calcareous masses are more common than tissue showing 
a recognisable tubercular structure, but in both cases it has been 
found that tubercle bacilli, or their spores, are generally present 
in an active state in these remnants. Thus, Dr. Sidney Martin, 
in his paper on " healed " or retrograde tubercle, read at the 
meeting of the British Medical Association in July 1891, states 
that while the fibroid and pigmented miliary tubercle never 
contains any tubercle bacilli, the calcareo-caseous tubercle almost 
constantly does. Similar conclusions have also been arrived at 



SPONTANEOUS CURE. 125 

by other observers, both from microscopical observations and 
from experiments on animals, and clinically we know that these 
encapsuled deposits often contain the tubercular virus in an 
active state, from the frequency with which the tubercular 
disease recurs after an injury causing rupture of the encap- 
sulating material. Hence we can only speak of cure in those 
cases where the result is more or less fibroid induration with 
complete disappearance of the tubercular material. Encapsula- 
tion of a deposit is not true cure, but its occurrence, never- 
theless, illustrates the fact that the bacillus often has a hard 
struggle for existence in the human body, and often fails to 
make headway or even to hold its ground. 

What exactly happens when " spontaneous cure " occurs is 
not quite clear. No doubt in cases of true cure the bacillus 
is in some way or other destroyed, and then the process 
naturally at once comes to an end, but in the case of encap- 
sulation this is clearly not the explanation, for, as I have 
just mentioned, these encapsuled deposits usually contain active 
bacilli or spores. It must be that something or other has 
either led to temporary diminution of virulence of the bacilli, 
or to cessation of chronic inflammation around the deposit, or 
to both, with the result that the inflammatory tissue around the 
tubercular deposit has developed into fibrous tissue, and formed 
a capsule around it which prevents the further spread of the 
disease, so long as this capsule remains uninjured. Whatever 
be the cause which leads to this result, it seems to be in most 
cases a local one, for not unfrequently while a tubercular 
process in one part of the body is improving, a fresh outbreak 
may occur elsewhere. Similar changes in the local condition 
are often seen to occur in a reverse direction without any dis- 
cernible cause, for example, the patient's health may remain 
good and yet an abscess develops in connection with the local 
disease, which has remained up to that time very much in 
statu quo, and this due not, as is supposed by some, to mixed 
infection from the accidental entrance of pyogenic organisms, 



126 CURABILITY OF TUBERCULOSIS. 

but to extension of the tubercular process. In connection with 
the retrogression of tubercle, it is very curious to note in 
almost all the statistics, notably in Heitler's, and in those 
published in the British Medical Journal by Fowler and Sidney 
Martin, the large proportion of cases dying of cancer in which 
obsolete tubercle was found, as if either the change in the 
tissues which led to the cessation of the tubercular process pre- 
disposed them to the cancerous invasion, or the occurrence of 
cancerous disease led to the cessation of the tubercular process. 
These changes indicating healing or retrogression have been 
most carefully studied at the apices of the lungs, and in these 
parts they occur either as fibrous and often pigmented 
indurations without any trace of tubercular structure, or as 
encapsuled deposits, generally cheesy or calcareous, but some- 
times still showing tubercular elements. The frequency with 
which these evidences of arrest of tubercular disease is found 
at post-mortem examinations is variously given by different 
authors. Thus, Heitler, in a paper published in the Wiener 
Klinik in 1879, states that in 16,562 post-mortem examinations, 
obsolete tubercles, or rather calcareo-caseous nodules, were 
found in the lungs in 789 cases or about 4 per cent, of the 
whole; Fowler, in a much smaller number of post-mortem 
examinations, found signs of obsolete tubercles in 9 per cent., 
and Sidney Martin in 9 -4 per cent., while Coats gives the 
frequency in patients dying of non-tuberculous diseases as over 
23 per cent., and Harris as 38 per cent, in persons over 20 years 
of age. Harris, however, states that in some of his cases 
evidences of active tubercle were found on microscopical 
examination, and as all were not examined microscopically he 
thinks that the proportion of " healed " tubercle would require 
to be considerably reduced. As to the relative frequency of 
fibroid changes which, if resulting from tubercle, imply really 
cured lesions, and of encapsulation of tubercular deposits, 
Sidney Martin found the ratio to be 1 : 4, thus reducing his 
percentage of really cured tuberculosis to 2-7 per cent, in post- 



RECOVERY IN BONE DISEASE. 127 

mortem examinations of patients dying of non-tuberculous 
diseases. While, however, it is not certain that all these 
fibrous indurations have really resulted from tuberculous 
deposits, it is probable that Martin's figures represent fairly 
accurately the facts of the case. 

With regard to surgical tuberculosis I can give no definite 
figures, but no doubt there are a considerable number of cases 
in which healing or encapsulation of tubercular lesions occur 
even without treatment. I should think that encapsulation of 
calcareo-caseous deposits occurs probably more often in glands 
than anywhere else. In the case of tubercular glands we 
frequently see, that while some suppurate, others remain 
enlarged and, as years pass, gradually diminish in size ; while 
we know, as the result of operations for the removal of tuber- 
cular glands, that these contain caseous material. 

As regards diseases of bones and joints I should say that, in 
the case of pure synovial disease, we have in a good many cases 
a true recovery, though in others there often remains, some- 
where or other, an encapsuled tubercular mass. On the other 
hand, where there are deposits in the ends of bones, encap- 
sulation is the rule in the great majority of cases which recover 
without operation or abscess. In fact, although I have 
examined microscopically a considerable number of bones with 
old standing quiescent tubercular lesions I have only once 
found appearances which justified the view that a bone deposit 
had been really cured; in all the other cases encapsulation 
and calcareous deposition had occurred and the deposit re- 
mained as a constant source of danger. As regards anchylosis, 
although in the case of bony anchylosis I have seldom 
found distinct traces of tubercular tissue except where 
tubercular deposits were present in the bone, I have, in most 
cases of fibrous anchylosis, found remains of tubercular tissue 
somewhere or other. This is a point of great importance in 
connection with the practical question of breaking down these 
joints with the view of obtaining better position or possibly 



128 CURABILITY OF TUBERCULOSIS. 

movement. Experience has taught the great danger of such 
procedures and the explanation is furnished by the fact which 
I have just stated. 

In considering the causes which oppose recovery in cases 
of tubercular disease, in other words, the points to which we 
must direct our attention in treatment, we find that they may 
be conveniently divided into two groups, viz., those affecting 
the power of the tissues and the body generally in overcoming 
the parasite, and those more directly connected with the 
parasite itself. In tuberculosis the factors on the part of the 
body which aid or resist the efforts of the parasite are per- 
haps of greater importance than in the case of any other 
infective disease, and it is seldom that the bacillus of itself 
can overcome the body, unless the conditions on the part of 
the host, both local and general, are favourable or, at any rate, 
not unfavourable to its action. I must therefore enumerate 
the more important of these factors in the first instance, 
and I shall do so under two headings — 1. Those common to 
the body as a whole ; and 2. Those peculiar to the part which 
is the seat of disease. 

1. General Causes. 

Perhaps the most important general cause affecting the 
spread of the tubercle bacillus is the peculiar constitutional 
condition present in patients who have inherited a tendency to 
the development of tuberculosis. While, as I have already 
pointed out, there seems no real ground for believing that the 
actual tubercular disease itself is transmitted from parent to 
child, except in extremely rare instances, it is .certain that for 
some reason or other the children of tuberculous parents are 
very liable to contract the disease. This fact admits of 
two explanations. In the first place, the members of a tuber- 
culous family are very often more exposed to infection than 
those of healthy families. Take a family in which one of the 
parents is dying of phthisis. The constant association of the 



RISK OF INFECTION. 129 

members with the patient inseparable to family life, the use of 
the same food utensils, the inhalation of dust containing dried 
sputum, kissing, &c, means that the healthy members are ex- 
posed to infection in an unusual degree, and explains to a great 
extent the occurrence of the disease in the others. And this 
great exposure to infection continues after the death of the 
patient, especially if the family continue to live in the same 
house and use the same bedding, &c, without any attempt at 
disinfection. Cornet, in the account of his elaborate researches 
on the distribution of tubercle bacilli, has shown the great 
infectiveness of the dust in rooms where phthisical patients 
have slept, and by the statistics of Prussian convent life the 
great danger of family life in the same building where in- 
dividuals are affected with or have died of phthisis. And it is 
no answer to this to point to the results in consumption 
hospitals where nurses escape to a large extent, for the infec- 
tion is not conveyed by the breath, and in these hospitals the 
nurses insist on the patients expectorating into suitable vessels, 
they do not use the same food utensils, nor do they kiss the 
patients. And there are numerous instances where the only 
members of a tuberculous family who have escaped the disease 
are those who have been sent away from home in early life, and 
kept away under the idea that it was the climate or situation 
of the house which led to the disease ; such persons being in 
reality thus removed from this prolific source of infection. 

Apart, however, from the greater risk of infection under 
these circumstances, there can be no doubt that the children of 
tuberculous parents, as a rule, yield more readily to the attack 
of the parasite than others, and that even though their hygienic 
surroundings are excellent. In explanation of this general 
tendency we may suppose either that some peculiar form of 
tissue change has been acquired and transmitted, which renders 
the body a better soil for the growth of the tubercle bacillus ; 
or that a condition of the tissue cells has been transmitted 
in which they are not so sensitive in their reaction against 
9 



130 CURABILITY OF TUBERCULOSIS. 

tubercle bacilli, nor so powerful as antitoxic or antiparasitic 
agents. It is quite possible that both of these conditions may 
be at work, and frequently there is some local peculiarity, more 
especially affecting the size and shape of the chest, the rapidity 
of the lymph flow, &c, which is present as well. Transmission 
of cellular peculiarities and of peculiarities of tissue change 
are well known in the heredity of gout, of haemophilia, of pro- 
gressive muscular atrophy, of colour blindness, &c. So also in 
the case of acquired pathological conditions as in Brown- 
Sequard's hereditary epilepsy in guinea-pigs, in ichthyosis, 
polyuria, and even in immunity against infective diseases. Some 
authors are so impressed with the importance of this hereditary 
tendency that they look on everything else, even the tubercle 
bacillus as of secondary importance. 

It must also be borne in mind with reference to this question 
that children with a marked hereditary tendency are often 
sickly, apt to take cold, or suffer from sore throats, quite apart 
from any existing tubercular disease, and they are, therefore, 
kept too much in the house and in badly ventilated warm 
rooms, and in this way their tendency is increased and their 
bodily vigour diminished. 

The bad results of confinement in close and hadly ventilated 
localities, such as the foul alleys of cities, of want of fresh air, 
&c, as predisposing agents, need not be dilated on. They act 
partly by imperfect aeration of the blood, partly by loading it 
with noxious materials, which interfere with the healthy action 
of the tissue cells, and possibly also in the case of disease of the 
air passages, by leading to the introduction of other organisms 
which, by their growth side by side with the tubercle bacillus, 
enable the latter to grow better and aid the destructive changes. 
Not only the local conditions of the air but also the climate is 
of importance, either because it may not suit the general 
nutrition of the patient, some doing best in a cold climate, 
others in a warm one, some at the seaside, others inland, &c, 
or because certain peculiarities of the climate, more especially 



INFLUENCE OF CLIMATE. 131 

cold and excessive moisture, may predispose certain organs to 
attack by setting up a catarrhal inflammation, or weaken them 
when they are attacked. In the case of the lungs such a climate 
will predispose them to attack by setting up bronchitis and con- 
gestion, and in the surgical tuberculoses it may also exert an 
important influence. For example, tonsillitis is not uncommon 
under these conditions, and this may be followed by inflamma- 
tion of the cervical glands and subsequent tubercular infection. 
Similarly with regard to diseases of bones and joints, such a 
climate is liable to set up rheumatic inflammations, which in 
some cases may pass into tubercular disease, the part weakened 
by the rheumatic attack being rendered liable to tubercular 
infection. I have certainly seen several cases where a tuber- 
cular joint disease has been left after an undoubted attack of 
acute rheumatism, showing that there is no real antagonism 
between these diseases. 

With regard to this matter, however, we must not assume 
that all cases which commence with febrile disturbance and pain 
in more than one joint, &c, are in the first instance rheumatic ; 
Wiesner, Brissaud, and others have published cases in which 
the tubercular joint disease commenced in this way, and I have 
had one where the disease was ushered in by fever and pain and 
slight swelling, both in the shoulder and the knee, and where 
finally only the knee became diseased. 

The quantity and quality of the food are of considerable 
importance. Of course, if the food is insufficient in quantity 
and of poor quality, the general nutrition of the patient suffers, 
and he becomes more liable to infection and less able to resist 
the progress of the disease. Further, I have already referred to 
Bidder's view, that an excess of potash in the food favours the 
growth of the bacilli, and is probably in part the explanation of 
the much greater susceptibility of herbivora as compared with 
carnivora to tuberculosis, and it is certainly quite conceivable 
that by having an excess of certain substances derived from the 
food in the tissues of the body, they may be thereby rendered a 



132 CURABILITY OF TUBERCULOSIS. 

better or worse soil for the growth of the bacilli or less effective 
destructive agents. Brehmer also lays great stress on the 
quantity of the food in relation to phthisis, stating that small 
eaters are especially predisposed to this disease, the explanation 
he gives being, however, a mechanical one, depending on the 
effect which a frequently distended stomach may exercise on 
the shape of the chest during the period of growth. 

Attacks of certain diseases not only predispose to the tuber- 
cular infection, but also, occurring during the course of the 
disease, often aggravate it very much. This is especially the 
case with measles, and also with scarlatina, whooping-cough, &c. 

The frequent occurrence of strumous glands in the neck, and 
of mastoid disease following on otitis media after measles is 
well known, and similarly an attack of measles will often cause 
a very grave exacerbation of a joint disease. Not long ago I 
had two cases in the ward at the same time, which illustrated 
very well the bad effect which an attack of measles may exert 
on the progress of the disease. Both were cases of knee-joint 
disease, in which I had done a partial arthrectomy, dissecting 
away the whole of the synovial membrane in front and at the 
sides of the joint, but only scraping away what I could of the 
diseased tissue behind, without dividing the crucial or lateral 
ligaments. The wounds had healed and everything promised 
well, till just as the children were about to leave the hospital 
they were attacked by measles. As a result the scars rapidly 
broke down, and the disease recurred to such an extent that in 
the one case I had to do a complete arthrectomy, and in the 
other an intra-epiphysial excision. Even in the case of a mild 
disease, like a mild attack of chicken-pox, I have seen marked 
recrudescence of disease which had up to that time been steadily 
improving. The same predisposing effect of acute fevers to 
infective diseases is well known in the case of other affections 
than tuberculosis; for example, in the occurrence of acute 
suppurative periostitis and osteomyelitis, after typhoid and 
other fevers, &c. 



INFLUENCE OF INJURY. 133 

2. Local Causes. 

Passing now to the local causes which interfere with the 
action of the tissues in repelling the parasite, the most 
important are those which tend to set up, and keep up, a 
state of chronic inflammation in the part. T have already 
pointed out that the tubercular disease when spreading is always 
surrounded by a greater or less extent of tissue in a state of 
chronic inflammation, and that the disease tends to spread in 
the direction in which this tissue is most abundant. Of the 
causes which increase the chronic inflammation, apart from the 
presence of the tubercle, movement of the affected parts, and in 
the case of joints, pressure of the inflamed joint surfaces against 
each other, are the most important, and the improvement in 
the part when these two causes are removed is often very 
striking. 

Injury is also not only a potent factor in the production of 
these tubercular diseases, but, as we all know, is very apt to 
aggravate an existing lesion, or to light up a disease which may 
have been quiescent for a long time. In the lighting up of a 
quiescent lesion the effect of the injury is either to rupture the 
fibrous capsule surrounding the tubercular deposit or, where 
this fibrous tissue is only small in amount, to lead to passage of 
fluid into the deposit, thus providing fresh pabulum for the 
growth of the bacilli. Its action in aggravating an existing 
disease may be partly due to increase in the inflammation and 
partly to the accompanying swelling interfering with the lymph 
flow, and producing a stasis of lymph in the part, a condition of 
matters which is favourable to the growth of the bacilli. Dr. 
Wayland Chaffey has laid great stress on lymph stasis as a 
factor in the production of tubercular disease and in the 
exacerbation of existing disease, and though I am not inclined 
to go so far as he does with regard to the former view, the 
arrest of the lymph in the part seems to me to be a factor of 
great importance in connection with the spread of the disease. 



134 CURABILITY OF TUBERCULOSIS. 

Disturbance in the circulation of the blood must also be of 
importance — for example, where the disease affects the lower 
extremity, if the limb is allowed to hang the free circulation of 
blood in the part and the removal of waste products are inter- 
fered with, and, as we know, wounds under such circumstances 
do not heal, or only with great difficulty. 

Apart from these various factors on the part of the body, 
the conditions on the part of the tubercle bacillus itself may 
exercise a considerable influence on the spread of the disease, 
and although these conditions are not under the control of the 
surgeon, it is well to bear them in mind. I have formerly 
pointed out that the severity of an infective disease depends to 
a great extent on the initial dose, and this also holds good in 
tuberculosis. As cases of bone and joint disease no doubt arise 
not merely from individual bacilli carried to the part by the 
blood, but also and probably most commonly by actual emboli 
of tubercular material containing bacilli coming from some 
central focus, generally I think from the bronchial glands, the 
severity and acuteness of the disease will depend to some extent 
on the number of bacilli present in the original embolus. The 
virulence of these bacilli also varies to some extent, and it is 
found that if the virulence is diminished by artificial means, 
the attenuated bacilli tend to set up local lesions, resembling 
scrofulous diseases in man rather than the more acute general 
disease, which is the usual result in the lower animals. On the 
other hand, it has been found that the virulence of certain 
organisms is increased by passage through highly susceptible 
animals, and it may be that in the case of tuberculosis in highly 
predisposed individuals the bacilli may gain in virulence, and 
thus the children, apart from their hereditary predisposition, 
are apt to get a more acute form of the disease, as the result of 
the greater virulence of the bacilli, as well as from getting a 
large initial dose. Another thing which favours the growth of the 
tubercle bacilli is the concurrent growth of other organisms. 
In the case of the lung the presence of other organisms, more 



INFLUENCE OF SEPSIS. 135 

especially of the micrococcus tetragenus, seems to have a great 
deal to do with the rapid breaking down of the tissue, and in 
open tubercular deposits elsewhere there is no doubt that the 
presence of the ordinary pyogenic organisms leads to extension 
and persistence of the disease to a very marked degree. This is 
a point to which I shall subsequently return. 



CHAPTER XL 

TREATMENT OF TUBERCULAR DISEASE OF BONES 
AND JOINTS. 

Methods which Act on the Body — Prophylaxis — General 
Hygiene — Value of Eest and Extension. 

Before going on to the consideration of the methods of treat- 
ment, I may say a few words as to prophylaxis. The subject of 
prophylaxis belongs especially to the physician, but it has also 
to be considered by the surgeon, for many patients with surgical 
tuberculoses are also affected with phthisis, while in external 
tuberculosis there may be a certain amount of danger where 
the diseased tissue communicates with the surface of the body. 
To carry out a complete system of prophylaxis is a very difficult, 
indeed an impossible, matter under our present social conditions, 
but nevertheless a great deal can be done without any special 
inconvenience, provided the patient understands and cordially 
co-operates. As we now know, it is the dried-up secretions 
containing tubercle bacilli, which are the chief source of danger. 
In the case of phthisis, I doubt if the breath is at all dangerous, 
and there is no real risk in associating with a phthisical patient 
so long as one does not come in contact with or inhale the dis- 
charges from the seat of disease, and then only in all probability 
if there is a weak spot which may form a point of entrance. 
Hence isolation of the patient, as advocated by some, is not at 
all necessary if only he himself will aid in the matter intelli- 
gently. In the case of phthisis, which interests us in so far as 
it not unfrequently complicates cases of surgical tuberculosis, 
the chief stress must be laid on disinfection of the sputum, 
which should always be discharged into a proper receptacle, 



PROPHYLAXIS. 137 

containing a small quantity of fluid, preferably 5 per cent, car- 
bolic acid solution. Spitting into handkerchiefs, on the floor, into 
spittoons, &c, must be absolutely prohibited, and after spitting, 
the mouth must not be wiped by a handkerchief which is after- 
wards put in the pocket, but by cloths or other material which 
can be at once placed in a disinfectant solution or burnt. Kissing 
should be absolutely prohibited. The patient should also have 
a set of dishes, cups, knives, forks, &c, which should be reserved 
for his own use. It is also clear from Cornet's researches that 
the sleeping-room should be thoroughly cleaned out and disin- 
fected from time to time, and therefore there should be up 
more furniture in it than is absolutely necessary. From 
time to time he should move into another room, and have 
the one he has left thoroughly disinfected and aired ; the bed 
and bedding should also be disinfected, more especially the 
pillows, which are so apt to become soiled. I believe that if 
precautions of this kind were employed, we should hear less of 
member after member of a family succumbing to this disease. 
In surgical cases such precautions are, of course, only needful 
where phthisis is present, or where there are open sores. In 
the latter case, it is possible "that clothes, bedding, floors, &c, 
may become soiled with the discharge, and therefore the 
same precautions as to disinfection of rooms, bedding, &c, 
should be carried out as if phthisis were present. On the part 
of the predisposed also it is of importance that all food should 
be well cooked, milk boiled, injuries avoided, &c. 

It is interesting to note that more than one hundred years 
ago laws of extreme stringency were promulgated at Naples, 
which show most advanced views as to the infectiveness of 
phthisis. Among them I may mention that doctors had to 
notify every case of phthisis under a penalty for the first offence 
of 300 ducats, and on a second conviction of banishment for ten 
years ; poor patients must be at once sent to hospital ; all clothes 
worn by phthisical patients must be kept separate ; an inventory 
must be taken of all the clothes and linen of the patient, and 



138 TREATMENT OF TUBERCULAR DISEASE. 

this had to be accounted for after death, the punishment on 
default being imprisonment or even the galleys. All possibly 
contaminated furniture had to be burnt or thoroughly disin- 
fected, the rooms papered and painted, doors and windows 
burnt, and those selling the clothes and effects of phthisical 
patients were liable to severe punishment. The result was that 
houses in which phthisical patients had lived could not be let, 
many people were ruined, and the law was evaded in every 
possible way, and was ultimately repealed as being useless after 
about sixty years. 

Coming now to the treatment of these tubercular diseases, 
we must consider it under two separate headings — 1. Methods 
of treatment, which aim at strengthening the body as a whole, 
or the affected part in particular, thus enabling the tissues to 
overcome the bacillus — methods, in fact, which do not act 
directly on the tubercular disease at all, but only indirectly 
through the tissues of the body ; and 2. Methods, of which the 
essential feature is the removal or destruction of the tubercular 
tissue, and with it of the tubercular virus. 

1. Methods which act on the Body and not directly 
on the Tubercular Disease. 

These methods may act generally or locally, or both. 

(a.) General Treatment. — The first essential in the general 
treatment of these cases is to put the patient under as good 
hygienic conditions as possible, and the first requisite is that 
he should have pure air, and plenty of it. Where it is possible, 
it is well for these patients to live in the country, but where 
this is not advisable, a good deal can be done by free ventilation 
and plenty of cubic space. 

In this connection the question of climate naturally arises, 
but that is one which I shall not enter into beyond a few 
general remarks. The first question which we have to consider 



CLIMATE. 139 

is, at what period of the disease the patient should be sent to 
a different climate. The conditions here are not so simple as 
in the case of phthisis. In that disease comparatively little 
can be done by local treatment or operative interference, and 
the treatment must be directed almost solely towards getting 
a better state of health and improving the condition of the 
lung ; in surgical tuberculosis, on the other hand, a great deal 
can often be done by local treatment — operative or otherwise — 
and it is always a question whether the local or the climatic 
treatment is, for the time being, of most urgent importance. 
In bone and joint disease it is mainly in the early stage, while 
there is as yet no question of operative interference, that the 
change of climate is of greatest value, or, again, after the neces- 
sary operative interference has been carried out ; where an 
operation is impending, or where such methods of treatment 
as extension are necessary, change of climate is, for the time 
being, inadvisable. The problem as to when it is best to send 
the patients to the country or when to keep them in town, so 
that the local treatment may be carried out under one's own 
superintendence, is thus a very difficult one, and quite different 
from that which has to be faced in connection with phthisis. 

Having decided to send a patient away, the next question is, 
Where he should go and what amount of liberty he should 
have. The determination as to place will depend to a consider- 
able extent on the view which one takes as to the action of 
climate in the treatment of tuberculosis. Two views are held 
with regard to this matter — the one, that in the air in certain 
localities substances are present which have a specific anti- 
tubercular action ; and the other, that the usefulness of climate 
depends on its effect in improving the general condition of the 
body, thus acting only secondarily on the tubercular disease. 
The first view is that which is generally held by the laity, more 
especially with regard to sojourn at the seaside and to sea 
voyages, and it is no doubt the mainspring of the remarkable 
pilgrimage to Margate which seems to be the first and most 



140 TREATMENT OF TUBERCULAR DISEASE. 

essential part of the treatment of surgical tuberculosis in their 
minds — a pilgrimage undertaken without the slightest con- 
sideration as to whether that is the climate which suits the 
patient best or not. Indeed, I have known patients persist in 
staying at the east coast health resorts, although they were 
never well there, on the idea that, though their bodily health 
was suffering, their tubercular disease was being cured by 
the specific substances (iodine, ozone, or what not) contained 
in the air. This is, I am satisfied, an erroneous and hurtful 
superstition, and I agree with the view taken by the great 
majority of the authorities on climate — viz., that the efficacy 
of climate as an anti-tubercular agent depends solely on its 
action in re-establishing the vigour of the body and enabling 
it to oppose successfully the parasitic invasion. From this 
point of view there is no one place which will suit all cases, 
and the decision must depend on a knowledge of the peculi- 
arities of the patient, and on the stage and situation of the 
disease. 

The first point to ascertain is the temperature which suits 
the patient best, some preferring hot weather, others being well 
only in a cool place. The question of temperature must also 
be considered in connection with the possibility of the patient 
taking active exercise in the open air. Where a, patient is 
unable to walk, the place chosen must be warm and dry, and 
it must also be sheltered from winds, because he ought to be 
out in the open, as far as possible, all day. Many patients 
undoubtedly do best at the seaside, but there are others — and 
I am not sure that they are not in the majority — for whom 
somewhat high inland situations are the most suitable. In 
the case of the latter patients, I believe the best thing to 
do is to send them to a farm-house in a high, dry inland part, 
such as Yorkshire in summer, Devonshire in winter, and let 
them be as much in the open air as possible. Where a seaside 
place is chosen, I think that in the early stage of the disease, 
or where the patient is weakly, the south coast health resorts 



EXERCISE. 141 

are preferable, as a rule, to those on the east coast, although, 
after the disease has improved or been got rid of by operation, 
the east coast stations in summer often brace up the patient 
extremely well, and, so to speak, put the finishing touches to 
the treatment. 

Another point of importance in connection with a sojourn in 
the country is the question of exercise. Where the disease is 
situated in the upper extremity there need be no difficulty 
as regards walking exercise, which, however, should never be 
carried so far as to tire the patient. While, however, exercise 
and fresh air are invaluable, the great tendency of injuries to 
lead to fresh outbreak of the disease should also be borne in 
mind, and amusements or pursuits should be avoided in which 
there is an unusual risk of injury, especially of sprains. 

Where the disease is situated in the lower extremity, however, 
I do not think that attempts at walking are good. Under 
these circumstances patients are usually fitted with an apparatus 
to keep the joint at rest, and provided with crutches and a 
patten on the sound side, and told to get about as much as 
possible. In other instances, especially in some cases of knee- 
joint disease, an immovable apparatus of silicate or plaster is 
applied, and the patient is allowed to walk about; this is 
radically wrong. It is no doubt unavoidable in the case of 
poor patients that they should be allowed to get about, but it 
is not, I believe, good treatment in the majority of cases. As 
we know from the clinical history of ulcers and inflammations 
of the leg, the dependent position of the limb interferes with 
the circulation and nutrition of the part very much, and the 
same must be the case where there is tubercular joint disease, 
and it must be still worse where the weight of the body is 
borne by the diseased joint. In such cases I believe that it is 
better that the patient should be kept in a recumbent position, 
wheeled into the open air, and exercise given him in the form 
of general massage. No doubt, this is only practicable in the 
well-to-do, but neither is change of climate practicable for the 



142 TREATMENT OF TUBERCULAR DISEASE. 

poor, except for a limited number and for a short time, while, 
for a small fee a relative or attendant can acquire a sufficient 
knowledge of massage to enable them to do what is necessary. 

As to diet, it should be as nutritious and easily digested as 
possible, the meals should be more frequent than normal, con- 
siderable quantities of fat, or in its place cod liver oil, should 
be given, and iti accordance with Bidder's views, to which I have 
referred, substances containing much potash should be avoided, 
more especially excess of vegetables, of which, according to Dr. 
"Weber, potatoes are especially bad. As to medicine, general 
tonics and substances to improve the digestion, cod liver oil, 
&c, are indicated, but these must be considered in reference to 
the individual case. 

(b.) Local Treatment — With the object of improving the 
condition of the tissues at the seat of disease, so as to interfere with 
the existence and extension of the tubercular virus, and not with the 
view of acting directly on the tubercular disease. — We have already 
seen that one of the chief local obstacles to recovery is the 
state of the parts indicated by the condition of chronic inflam- 
mation, and that there are, apart from the presence of tubercular 
tissue, two very evident causes which keep up this condition — 
viz., a condition of unrest, such as may be caused by movement 
or sepsis, and, in the case of joints, pressure of the diseased 
surfaces against each other. I shall, therefore, shortly refer to 
some of the means of avoiding these troubles, and of diminish- 
ing this chronic inflammation. The methods of treatment 
which act on this principle are grouped together under the 
heading of expectant treatment. 

In combating this condition the first requisite is, as far as 
possible, to give absolute rest to the part, rest both from 
mechanical agencies and from chemical irritants, such as sepsis. 
The value of absolute mechanical rest is so great and so 
universally acknowledged, that one would think that in this 
matter, at least, there could not be any difference of opinion, 
and yet, so eminent a surgeon as Schede holds that complete 



REST. 143 

immobilisation of tubercular joints is a burtful thing, as 
evidenced by the frequent occurrence of effusions into healthy 
joints after they have been kept at rest for a long time and 
then left free, and he asserts that the cessation of the 
function of the joint leads to atrophy, that the synovial 
secretion ceases, the capsule shrinks, and movement becomes 
difficult and painful. He, therefore, in the case of hip-joint 
disease, applies extension without any other retentive apparatus, 
and allows the patients to move about in bed, and even in some 
cases encourages them to sit up, and he attributes the less 
satisfactory results which he has got in knee-joint disease as 
compared with hip-joint disease, partly to the lesser degree of 
movement which has been permitted in that joint. I doubt, 
however, if even Schede's name will suffice to lead surgeons to 
give up such a generally accepted view as the necessity of 
placing parts which are affected with tubercular disease as 
completely at rest as possible. 

In the case of tubercular joint disease, surgeons, with very 
few exceptions, are unanimous in recommending rest, and it is 
sometimes very striking how much improvement results, even 
in very bad cases, from absolute fixation of the affected joints. 
In many cases of joint disease, the unrest is, however, not only 
due to movement, but also to a large extent to the tonic con- 
traction of the muscles surrounding the diseased part and 
causing pressure of the joint surfaces against each other. 
When the bone has become affected, the joint is always found 
to be more or less completely fixed, the fixation being due in 
the early stage almost entirely to reflex contraction of the 
muscles surrounding it. The result is that the joint surfaces 
are kept constantly and firmly pressed against each other, and, 
as a consequence, the chronic inflammation in the bone is kept 
up, and rapid destruction of the surface of the bone subject to 
the pressure takes place. This is seen in the hip-joint, for 
example, in the flattening of the upper surface of the head of 
the bone, and in t^he enlargement of the acetabulum in the 



144 TREATMENT OF TUBERCULAR DISEASE. 

upward and backward direction. This muscular contraction, 
especially in the early stage, may be looked on as symptomatic 
of inflammation of the bone ; in pure synovial disease, there 
may be marked thickening with comparatively little inter- 
ference with movement within certain limits, certainly without 
complete rigidity. 

Hence, when the bone is inflamed, mere rest of the joint as 
obtained by fixation apparatus will not be sufficient ; the muscles 
would still be able to contract and keep up the pressure and 
inflammation. It is, therefore, necessary in these cases to 
combine with the rest a moderate amount of extension sufficient 
to tire out the muscles, and prevent this violent pressure of 
the joint surfaces against each other. Many surgeons object 
strongly to extension, under the impression that its object is 
to separate the joint surfaces from each other, and have pointed 
out that, unless .very heavy weights are employed in most 
cases, no separation of the joint surfaces can be effected, while 
such weights may do great injury to the joint by stretching 
and irritating the inflamed ligaments, and not only to the 
affected joint but also to the healthy joints below. This is 
perfectly true, but separation of the joint surfaces ought not 
to be the object of the extension, and, even if it were readily 
possible, is not at all desirable. The object is not to separate 
the joint surfaces, but to prevent them from being pressed 
together — two totally different things. Hence, extension is 
chiefly of use in bone disease. 

Where the case is one of pure synovial disease, and where 
there is no marked rigidity of the muscles, there is no object in 
employing extension unless deformity is present ; in fact, it 
will probably do harm. And further, from this point of view, 
it must be borne in mind that a weight which, in the first 
instance, relieves the patient, may, if continued after the tonic 
contraction of the muscles has been overcome, cause a great 
deal of pain and mischief from stretching of the inflamed 
ligaments. For example, to take a case recently under my 



EXTENSION. 145 

care, a man with hip-joint disease of 9 months' standing, com- 
plete rigidity, and great pain, especially in the knee, and starting 
of the limb at night, the employment of a 5 lb. weight at once 
relieved his pain, a long splint being also used. Thirteen days 
later he began to complain of pain about his hip-joint, especially 
in front, and this was relieved by reducing the weight to 3 lbs. 
Ten days later there was return of this same pain, which at 
once disappeared on leaving off the extension and employing 
the long splint alone. In this case, I have no doubt that the 
muscular rigidity gave way more rapidly than usual, and that 
the fresh pain was the result of undue stretching of the 
inflamed capsule. It is, therefore, important in these cases 
to watch the extension, and to diminish the weight as 
soon as it is evident that the muscular resistance has been 
overcome. 

I may perhaps best illustrate the value of extension in tuber- 
cular bone disease by considering its effect in disease of the 
spine with paralysis. In spinal disease there are, in addition 
to the presence of tubercle, two factors at work in keeping up 
the chronic inflammation, and thus causing the destruction of 
the bone and the consequent curvature, viz., 1, the weight of 
the upper part of the body; and 2, the contraction of the 
muscles around the diseased portion of the spine, keeping the 
inflamed bones tightly pressed against each other. The in- 
flammation so kept up is apt to spread to the meninges causing 
thickening of them, pachymeningitis, which may be either of 
a simple inflammatory nature, or may be combined with tuber- 
cular infiltration; this thickening of the meninges leads to 
pressure on the cord, and is one of the causes of paralysis. 
This condition of pachymeningitis being, as I have said, kept up 
to a great extent in unison with the osseous inflammation by the 
action of the weight of the body and of the muscular con- 
traction, it is clear that the first indication as regards treat- 
ment in a case of paralysis is to see what can be done by 
relieving these conditions. The best way of doing so is, I 
10 



146 TREATMENT OF TUBERCULAR DISEASE. 

believe, by the use, in addition to complete recumbency, of 
extension to the head and feet, although I have seen improve- 
ment follow recumbency alone, especially when combined with 
the use of the actual cautery ; this is a point which I shall speak 
of presently. It is, I think, becoming too much the fashion 
nowadays to perform the operation of laminectomy at once in 
these cases in order to relieve the pressure on the cord ; I think 
that in all cases a preliminary trial should be given to double 
extension, and that probably most cases would yield to that 
treatment without operation ; that certainly has been my 
experience. 

The great importance of the second factor, viz., the tonic 
contraction of the muscles surrounding the spine, in keeping up 
the inflammation of the bone and leading to the subsequent 
paralysis is not, I think, thoroughly realised, and the result is 
that it has appeared to some that the object of extension to the 
head and feet in these cases was to undo the curvature of the 
bone, an attempt which would probably only do harm. I have 
been surprised that this factor has not been more generally 
recognised, seeing that Lannelongue, who is undoubtedly the 
highest authority on the pathology and treatment of spinal 
disease, has laid special stress on the production of curvature 
and the extension of the disease as the result of this tonic con- 
traction of the muscles surrounding the seat of disease, and on 
the value of double extension as a means of overcoming this 
trouble. Lannelongue states in illustration of the effect of 
this muscular contraction that he has seen a curvature occur 
while the patient has been kept absolutely at rest in the 
recumbent posture, and where the weight of the body could 
not therefore be the cause. I have seen the same thing in a 
case where a psoas abscess was opened and drained in an adult, 
and where the patient was kept absolutely recumbent and 
never allowed to sit up or raise his shoulders for any purpose 
whatever. When put to bed there was no distinct evidence of 
curvature, but after some months an acute curvature was quite 



EXTENSION IN PARAPLEGIA. 147 

manifest. Here also the weight of the upper part of the body 
could not be the cause. 

I shall mention three cases to illustrate the advantage of 
extension. The first case is that of a boy aged 4-1- years, who 
was admitted to Paddington Green Children's Hospital on 
6th April 1888. Three years and a half previously the child 
developed a tubercular knee-joint disease after a fall, and this 
was under treatment for three years with good result. About 
2^ years before admission the back was noticed to be weak, 
and the child was treated at a general hospital first by plaster 
of Paris jackets, and subsequently by these combined with a 
jury mast which he was still wearing when he came to 
Paddington Green. The curvature had been getting more 
marked and the child was rapidly losing flesh. He had been 
unable to walk for nine months ; during the last three months 
the legs had been rigidly extended. There was no history as 
to the anEesthesia. 

State on admission : — The patient is a delicate-looking child, 
fairly well nourished : both lower limbs somewhat wasted. 
There is a well-marked antero-posterior curvature affecting 
the 8th, 9th, 10th, and 11th dorsal vertebras; no pain on 
tapping the spine, T. 100-8°. There is almost complete 
muscular paralysis of both lower limbs with wasting of the 
muscles, he can only make the very slightest movements and 
that after great exertion. Bladder and rectum not affected. 
Skin and patellar reflexes much exaggerated. Marked con- 
traction in lower limbs at knee-joint in whatever position 
leg is placed. Sensibility to touch and pain is absolutely 
lost in both legs up to groin, and there is an area of 
diminished tactile and painful sensibility on the abdomen up to 
the level of the umbilicus. 

In this case, seeing that the paresis had lasted so long, I 
thought that laminectomy was certainly required, but while 
waiting till it was convenient to perform it extension was 
applied to the head and legs with weights of 3 lbs. at each 



148 TREATMENT OF TUBERCULAR DISEASE. 

part, and the patient was put on 20 grain doses of benzoate 
of soda every four hours. On April 12th it was noted that 
there was marked improvement as regards sensation which was 
now present, though still much below normal, in both lower 
limbs; the proposed operation was therefore deferred. On 
April 25th it is noted that there was slight increase in the motor 
power, diminution in the patellar reflex, and considerable im- 
provement in sensation. And on the 28th the sensation to 
pain, heat, and cold was quite normal in both limbs, the sensa- 
tion to touch had also improved, but was not yet quite normal. 
The next note is on June 2nd when it is said that the patient 
can move the limbs quite freely in bed, and that sensation was 
normal, on the left side the knee jerk was still increased and 
ankle clonus was present; on the right the knee jerk was 
normal, and there was no ankle clonus. Towards the end of 
June he had an unexplained febrile attack from which, however, 
he soon recovered, and was sent to the convalescent home in a 
Phelps' box on July 14th. 

This patient improved steadily and towards the end of 1890 
was allowed to give up the Phelps' box, and was fitted with a 
light support. Pour months later he fell while climbing, and 
had recurrence of pain in his back, and was put back in the 
box. In July 1891 he went to Margate for ten weeks, and on 
his return was found to have some recurrence of the paralysis. 
He was re-admitted on October 27th, 1891, but owing to an 
outbreak of diphtheria in the ward he was sent to the con- 
valescent home four days later, where double extension was 
again applied. He subsequently recovered. 

In this case the immediate effect of the double extension was 
very striking, and the only possible fallacy would be that the 
improvement was due to the benzoate of soda. Though I have 
in one or two cases seen improvement which I could only 
attribute to this drug, I have never seen anything so rapid or 
striking, and I cannot think that this objection is of much 
importance. 



EXTENSION IN PARAPLEGIA. 149 

In the second case which I shall mention the trouble was not 
so marked. It is that of a boy aged 11, who was admitted 
under my care at King's College Hospital, on January 8th, 1890. 
Three years previously he noticed that his back was " growing 
out," but he had no pain and did not seek advice till ten months 
before admission, when he found that his legs were getting 
weak ; this weakness gradually got worse, till, for the last 
three months he has been unable to walk and hardly able to 
move his legs in bed. On admission he was found to have an 
angular and also, to some extent, lateral (concavity towards the 
right side) curvature in the mid dorsal region, involving four or 
five vertebras with acute prominence at the middle. He could, 
with great effort, move his legs slightly, but was quite unable 
to stand. There was no impairment of sensation. The patellar 
reflexes were exaggerated ; there was ankle clonus on both sides, 
most marked on the left. No bladder or rectal trouble. 

Extension by weights of 3 lbs. each were applied to head and 
legs and the body fixed between sand bags. 

On January 13th it is noted that the ankle clonus is 
distinctly less and that the patient can move the legs better. 
His condition rapidly improved, and on April 29th he was 
sent to a convalescent home in a Phelps' box, the reflexes 
being then normal and the muscular power completely re- 
covered. He was kept in this box till February 15th, 1892, 
when, as he seemed quite well and had, in fact, been getting 
out of the box for the last two or three months without the 
knowledge of the nurses, he was allowed to leave it off. He 
was then able to run about quite well. 

The third case was that of a girl, aged 13 years, who was 
admitted to Her Majesty's Hospital in connection with Dr. 
Barnardo's homes, on the 1st of October 1891. In December 
1889 her left foot was amputated on account of tubercular disease. 
In the autumn of 1890 she began to complain of numbness in 
her legs with difficulty in walking, but at that time no lesion 
was discovered. An angular curvature, however, developed soon 



150 TREATMENT OF TUBERCULAR DISEASE. 

afterwards in the upper dorsal region, and she was therefore 
placed in the infirmary in connection with the Ilford homes 
in the beginning of May 1891, and kept recumbent for some 
months. As she did not improve she was transferred to Her 
Majesty's Hospital on 1st October 1891. Towards the end of 
November her condition was as follows : — There was an 
angular curvature in the upper dorsal region, involving four 
vertebrae (4th, oth, 6th, and 7th), and not very abrupt. There 
was complete paralysis of motion in both lower extremities and 
complete anaesthesia as high as the ribs. Increased knee jerk. 
Inability to control the bowels, but she knew when they were 
going to act. Increased frequency of micturition but no 
incontinence. 

At that time Dr. Milne, the acting medical officer, asked me 
to see the case with a view to laminectomy, and I advised him 
to apply double extension to head and legs till I could arrange 
to come down, and if necessary operate. This was done on 
November 30th, weights of 4 lbs. each being used. Three days 
later it was noticed that she could move her toes, and she 
could feel a touch there and also over the lower part of the 
body and both thighs. On the 10th of December she could 
draw up her legs, and sensation had much improved. She was, 
however, at that time much troubled with incontinence of urine. 
The paralysis of the legs steadily improved, and had quite 
passed off in about six weeks, the rectal trouble was well, and 
the incontinence of urine had also improved. At the beginning 
of March an abscess was found in the posterior triangle of the 
neck, which was opened and found to lead towards the diseased 
spine. This did well. The spine was also decidedly less 
curved than before the treatment was commenced. 

The thing which strikes me as so remarkable in these cases is 
the very early improvement which takes place, so early, indeed, 
as almost to tempt one to think that after all some slight opening 
out of the curve must have taken place relieving the pressure. 
Although when the extension is long continued some slight im- 



EXTENSION. 151 

provement in the curve does occur in some cases, I cannot think 
that this is the explanation of the improvement in the paralysis- 
I believe that the relief is due to the rapid cessation of the 
congestion of the membranes and absorption of inflammatory 
material, as the result of the relief of the undue pressure of the 
inflamed bones on each other. 

Although in these cases the operation was avoided by the 
employment of rest and double extension, and although I believe 
that most cases would yield to that treatment, I am far from 
saying that laminectomy is not sometimes necessary. In the 
instances I have related the cause of the paralysis was no 
doubt a pachymeningitis, which was kept up by the irritation 
caused by the weight of the body and the tonic contraction of 
the muscles surrounding the spine. In other cases, however, in 
addition to the inflammatory thickening, the membranes are 
infiltrated with tubercular tissue which may not yield to treat- 
ment within a reasonable time, and for the relief of which it may 
be necessary to slit up the meninges. Or, again, the pressure is 
not uncommonly due to the presence of pus in the spinal canal, 
and unless this pus communicates with an abscess outside the 
canal, which can be opened, thus relieving the pressure, the 
only way of getting rid of the trouble will be by laminectomy. 
What I wish to urge, however, is that the operation should not 
be performed till double extension and rest in the recumbent 
position has been efficiently employed for at least two or three 
weeks. The same principle of extension first, followed by the 
use of proper retentive apparatus is, I believe, the best routine 
treatment, wherever applicable, in the case of tubercular joint 
disease, where there is either superficial or deep disease of bone, 
as evidenced by fixation, &c. In this way, also, deformity can 
be most quickly and satisfactorily overcome. I should not, 
however, as I have said, advise extension in cases of pure 
synovial disease, unless where deformity is present, and then 
only till this is corrected. 



CHAPTER XII. 

TREATMENT OF TUBERCULAR DISEASE OF BONES 
AND JOINTS— Continued. 

Methods which do not act directly on the Bacilli — 
Counter Irritation — Arthrotomy — Pressure — Massage 
— Koch's Treatment — Local Injections. 

Benefit is also derived in some cases from other measures, 
which are of known value in cases of chronic inflammation 
uncomplicated with tuberculosis. In a case of chronic osteitis 
or periostitis, the first thing that one suggests, in addition to 
rest and elevation of the part, is counter irritation in some form 
or other. In other cases one makes free incisions into the 
affected part, sometimes combined with partial removal of the 
inflamed tissue, and where the soft parts are affected pressure 
carefully applied is sometimes of advantage, as also is massage. 
These measures also do good in some cases of tubercular disease, 
I believe, by reducing the chronic inflammation around, and 
thus bringing the parts into a healthier state, and I may there- 
fore make a few remarks with regard to them. 

Although counter irritation is a favourite remedy in cases of 
simple chronic inflammation, and was formerly much employed 
in tubercular disease, yet, under the erroneous idea that the 
only object of local treatment in these cases is to act directly 
on the tubercular tissue, counter irritation has been thrown aside 
by many, and some forms of it, especially the use of the actual 
cautery, have been derided. As I am trying to show, however, 
a great deal can be done in these diseases by getting rid of the 
attendant chronic inflammation, and for this purpose the severer 



COUNTER IRRITATION. 153 

forms of counter irritation, viz., blisters or the actual cautery, 
are of value in suitable instances. In cases of pure synovial 
disease improvement sometimes follows the application of several 
blisters in succession, but where the bone is inflamed and is deep- 
seated, the most effectual method is the application of the 
actual cautery. 

The most suitable parts for its use are the hip and shoulder 
joints and the spine. I have not seen much good result from 
the use of the cautery in pure synovial disease, and in the case 
of superficial joints, such as the knee, I should fear that it 
would do harm by increasing the congestion of the synovial 
membrane. In applying the cautery in cases of bone disease, 
it must be done freely by means of a broad flat cautery at 
white heat, passed rapidly two or three times over a consider- 
able area of skin ; in the case of the spine, on each side of the 
spinous processes ; in the case of the hip and shoulder, both in 
front of and behind the joints. After the application of the 
cautery, warm boracic fomentations are applied till the slough 
separates, and then savin ointment, either pure or diluted with 
vaseline, is used, and the sore kept open for about six weeks. 
I believe the best results are obtained when only the superficial 
portion of the cutis is destroyed, and when, therefore, many nerve 
terminations are exposed. The objection to this is that it is 
very difficult to keep these sores from healing rapidly, and 
savin ointment often causes such pain that it cannot be 
employed. Under such circumstances, it may be necessary 
to open up the sores as they heal by the use of potassa fusa 
or by fresh application of the cautery. 

In 1888 I put together all the cases of tubercular diseases of 
bones and joints of which I could find notes, which had been 
under the care of Sir Joseph Lister or myself as in-patients, for 
several years. In this way, I made a list of 412 cases of 
disease of bones and joints, and, among these, the actual cautery 
had been applied in 24 instances, and in a considerable number 
with marked and immediate improvement ; in fact, in 17 of 



154 TREATMENT OF TUBERCULAR DISEASE. 

these 24 cases, or 70 - 8 per cent., no further operative treatment 
was required. I may mention one or two examples. 

In the case of the hip-joint, the cautery was applied in 7 cases, 
in 4 of which improvement followed and no further operative 
treatment was required, while in 3 no permanent good resulted, 
and, in these, abscesses were subsequently found in connection 
with the joints. I may mention one of the successful cases. It 
was that of a female, cet. 21, in whom the disease began 5 years 
previously, but had evidently followed a very chronic course. 
Four months before admission the pain increased and became 
constant, with starting of the limb at night. A Sayre's splint 
gave her temporary relief. On admission there was great pain 
on attempting movement, there was flexion and adduction, and 
1 inch of shortening. A long splint was applied with relief to 
the pain, but for some reason or other it was left off at the end 
of six weeks ; the pain at once recurred, and the splint was 
re-applied, but on this occasion without success. Extension by 
weight and pulley was then employed also without success, and 
accordingly, seven months after admission, the cautery was 
applied in front of and behind the joint, and the wound kept 
open for six weeks. The result was the almost immediate 
cessation of pain, and the patient was ultimately discharged 
seven months later free from all symptoms of active disease. 

In 6 cases of spinal disease, without abscess, the cautery was 
also employed, being freely applied on each side of the middle 
line, in all cases with improvement. In 4 of these cases there 
were commencing signs of pressure on the cord, and pain and 
sense of constriction around the waist. I may mention two of 
these cases. A man, cet. 43, was admitted with the history 
that, four years previously, he began to suffer pain in the lower 
dorsal region. About a year before admission a curvature was 
discovered, and of late he had suffered not only from pain in 
the back but also from a feeling of constriction around his 
waist, and pain shooting down both thighs. The cautery was 
freely applied on each side of the spine, and two days later he 



ACTUAL CAUTERY. 155 

had lost all his pain, and when discharged from the hospital 
seven weeks later, wearing a support, he was quite free from 
his symptoms. 

A male, at. 21, was admitted with the history that, seven 
years previously, he first noticed curvature in the dorsal region 
and since that time the deformity gradually increased, but he 
had no pain till twelve mouths before admission, when he began 
to suffer from pain and a sense of constriction around the waist, 
and this sensation had become worse of late ; the pain in the 
back was worse at night. No treatment had been employed. 
On admission, there was marked antero-posterior curvature in 
the dorsal region, pain on percussion and other signs as 
mentioned. Three days after the free application of the 
cautery, the pain in the back had entirely disappeared and 
also the sense of constriction, but these symptoms began to 
return about four weeks later as the sores healed. The sores, 
therefore, were opened up with potassa fusa and the pain again 
disappeared, and the patient left the hospital three months after 
admission quite free from his symptoms. 

Another method of treatment which is commonly employed 
in the treatment of simple chronic inflammation with the very 
best results is to make free incisions into the inflamed tissues, 
aseptically, of course, on the principle of relief of tension. In 
the case of chronic periostitis, there is no more effectual remedy 
than to make free incisions through the inflamed periosteum, 
and in the case of osteitis to gouge the inflamed bone exten- 
sively. In chronic enlargement of bursee free aseptic drainage 
will frequently effect a cure, and a certain proportion of hydro- 
celes are cured by incision and drainage. A good many years 
ago Sir Joseph Lister attempted to apply this same principle to 
the treatment of chronic synovial disease (the tubercular nature 
of the disease not being at that time thoroughly understood), 
and with a certain amount of success. To illustrate this matter 
of simple arthrotomy, let us take the knee-joint, which is the 



156 TREATMENT OF TUBERCULAR DISEASE. 

one most suited for this method of treatment. In performing 
arthrotomy of the knee-joint, in oases of tubercular disease, free 
aseptic incisions, 3 to 4 inches in length, are made on each side 
of the patella, the joint being thoroughly opened for the whole 
length of the incisions, and if the bone is thickened at any part, 
portions are gouged away. If there happens to be pus in the 
joint, it escapes, but in any case nothing further is done in the 
way of operative procedure. Drainage tubes are then passed 
fairly into the joint on each side, the wound is left gaping, 
aseptic dressings applied, and the limb placed on a posterior 
splint. In the cases to be mentioned presently this was the 
whole procedure; there was no washing out of the joint, no 
scraping, &c, and the after-treatment was simply the ordinary 
treatment of a wound, the dressings were changed when neces- 
sary, and the tubes were left out in the course of a week or ten 
days. These wounds generally heal, if they are going to heal, 
in from six to eight weeks, though in some cases while the 
greater part of the wound heals rapidly, a small sinus remains 
for several months. The treatment acts, as I have said, pro- 
bably by relief of tension, and the consequent subsidence of 
inflammation. That there is a considerable amount of tension 
in the part is evident from the manner in which the wound 
gapes when the incisions are small. It is possible, also, that the 
treatment may be efficacious in another way, for as the wound 
heals the young tissue contracts, and this pressure may exercise 
a beneficial effect. "Where the result is partially successful, it 
is not unusual to see a depressed scar at the seat of incision, 
with little or no thickening in its immediate neighbourhood, 
great improvement, or even cure of the disease having occurred 
around the incisions, but not elsewhere. Lastly, there may 
possibly be some meaning after all in the old formula of the 
induction of healthy action in the part. It is possible that the 
fact that the process of repair is going on actively and well at 
one part, may in some way that we do not understand, exercise 
a favourable influence on the neighbouring diseased parts. 



TUBERCULAR PERITONITIS. 157 

That good results may follow simple incisions into joints, the 
seat of tubercular disease, although none of the disease is 
removed, is not more surprising, indeed not so surprising, as 
that good results may follow simple laparotomy in cases of 
tubercular peritonitis, and yet there are now numerous cases on 
record in which the abdomen has been opened in cases of tuber- 
cular peritonitis, either intentionally or by mistake, and where, 
though nothing further was done, though the wound was simply 
stitched up again, considerable improvement, in some cases 
apparently cure, followed the incision. To go back on old 
statistics, Kummell has collected thirty cases of this kind, and 
of these only two died as the immediate result of the operation, 
both of them apparently from sepsis ; in three cases the patients 
died of general tuberculosis, five months, eight months, and one 
year later; in two cases lung trouble, which was previously 
present, progressed, but there was no return of the local disease ; 
the remaining cases improved both locally and generally, and 
the improvement continued up to the date of the last account 
published. The length of time that these cases had been under 
observation varied from some months to twenty-five years ; in 
ten or eleven of the cases the tubercular nature of the disease 
was confirmed by microscopical examination. Konig has since 
analysed 131 cases, of which 107 were cured, or, at any rate, 
much improved by the operation. I have lately had three 
cases of this kind where improvement, in all but one, how- 
ever, only more or less temporary, followed the operation, 
and I can offer no reasonable explanation of the facts ; the 
results appear to be better where the tubercle is in the form 
of largish masses, even when caseating, than where there is a 
general eruption of small grey tubercles over the intestines and 
peritoneum, at least that is my experience from my own cases, 
and from those I have seen. 

With our present improved methods of performing arthrectomy 
and treating chronic abscesses, I think that simple arthrotomy 
has a comparatively small field. When we have once gone so far 



158 TREATMENT OF TUBERCULAR DISEASE. 

as to lay open a joint, we may as well go somewhat further in most 
cases and remove at least as much of the tubercular material 
as is easily accessible. At the same time there are some cases 
where the disease is more or less stationary, or only progressing 
slowly, where an aseptic arthrotomy is sufficient to lead to 
recovery. The cases most likely to do well are those where the 
thickening of the synovial membrane is not very great, and is 
firm, and where, on cutting through it, no cheesy or softened 
spots can be seen. 

As regards the results, I may say that in the case of the 
knee-joint, which is the one most favourable for this treatment, 
there is in my statistics a, record of nineteen cases treated in this 
way, and of these nine got well without further operative treat- 
ment ; in most of the other cases pus was found in the joint 
when it was opened, and in these either repetition of the arthro- 
tomy or a partial arthrectomy was necessary, in three, indeed, 
amputation was ultimately performed. I may mention one or 
two of the cases : — 

1. A female, cut. 22, had suffered from disease of the 
knee-joint for thirteen years, which was, I should think, 
synovial in its origin. During the last seven months the 
swelling had increased, and the patient had suffered pain. 
On admission the joint was found to be much swollen, and there 
was pain on movement and on pushing up the leg. Blisters 
and posterior splint, extension and Saxtorph's apparatus were all 
employed without avail, and therefore free incisions were made 
into the joint on each side of the patella ; no pus was found in 
the joint. This was followed by great improvement and com- 
plete relief of the pain. The wounds healed in about two 
months, and the patient was discharged, wearing a water-glass 
apparatus, and much improved. 

2. Take next a case without pus in the joint, but with abscess 
outside. A female child, cet. 7, had suffered for two years 
from disease of the knee-joint, commencing after an injury. 
When admitted the knee was flexed ; there was an abscess of 



ARTHROTOMY. 159 

considerable size at the lower part of the thigh in front ; the 
synovial membrane of the joint was thickened, and there was 
pain on movement. The hamstrings were divided, the limb 
brought straight, the synovial membrane incised, and the 
abscess opened and drained. There was no pus in the joint, 
but the surfaces of the tibia and patella were felt to be in parts 
rough. The case did well, and the patient was discharged nine 
months later with the wounds healed, the knee much improved, 
and wearing a starch apparatus. This was removed two months 
later, when the knee was found to be normal in size. 

3. A male, mt. 17, with abscesses in connection with the right 
knee-joint, which were opened and healed. The patient was 
readmitted eighteen months later with swelling of the joint and 
a fresh abscess. The abscess was opened, and incisons were 
made into the joint, which contained some serous fluid. These 
wounds healed in about a month, but he began to complain of 
pain over the internal condyle of the femur, which became 
enlarged. An incision was made on the inner side of the joint, 
and a hole gouged in the bone (no cheesy deposit, however, being 
found), and at the same time the scar on the outer side of the 
patella was opened up, and the joint scraped. This treatment 
resulted in a cure. It should be mentioned, as regards this 
patient, that he had tubercular disease in various other parts 
of his body. 

The advantage of gouging the inflamed bone, quite apart from 
the removal of an osseous deposit, is also well shown in the 
following case, which, as a matter of fact, is the last in which 
I have performed arthrotomy pure and simple. 

4. Female, cet. 19. Disease of six months' standing, no 
history of injury. Has had swelling and pain since the com- 
mencement ; been treated in a variety of ways, but has steadily 
got worse ; amputation strongly urged in another hospital. 
Considerable thickening of the synovial membrane of a firm char- 
acter, and enlargement of the inner condyle of the femur, and 
of the inner tuberosity of the tibia. Free incisions were made 



160 TREATMENT OF TUBERCULAR DISEASE. 

into the joint, and holes were gouged in the inner condyle of 
the femur and inner side of the head of the tibia ; no tubercular 
deposits were found in the bones. Healed in less than two 
months, and the pain disappeared after the operation and did 
not return. She was sent out about three months after admis- 
sion, wearing a water-glass apparatus, and still remained well 
when last seen about two years subsequently. 

Of the other two methods of overcoming chronic inflamma- 
tion I need say nothing. Pressure has been long employed in 
the treatment of tubercular joint disease, more especially in the 
form of Scott's dressing, and some years ago Saxtorph recom- 
mended firmer pressure by means of large masses of cotton 
wool and silicate bandages. It seems to me that pressure must 
be very carefully employed, and that it is only of use in pure 
synovial disease. With massage also, which is recommended 
by those who seem to consider it a universal panacea, I think 
the very greatest care is required, and for my own part, with 
the exception perhaps of some stationary cases, I should not 
advise its employment. If used, the only permissible form is 
effleurage. 

2. Methods which act moke ok less directly on the 
Tubercular Disease. 

So far the methods considered do not act on the bacilli 
directly, they only aim at improving the general nutrition of 
the tissues, or diminishing or removing the inflammation around 
the tubercular deposit, thus putting the tissues in a better 
position to resist the invasion and destroy the parasite. We 
must now pass on to the consideration of the means which act 
more directly on the parasite and the tubercular tissue. 

Intermediate between the two stands Koch's tuberculin 
treatment — I say intermediate, because it is not yet known 
how it acts, whether simply by setting up inflammation and 



KOCH'S TREATMENT. 161 

causing infiltration of the tubercular tissue with leucocytes, or 
by some more direct action on the bacillus, or by breaking up 
its poisons, or by producing immunity by strengthening the 
cells of the body. I need not go into the matter of Koch's 
treatment in any detail, in fact I have nothing new to say about 
it, but I may mention the conclusions at which I have arrived. 
These are practically those which I stated in a paper read at 
the Medico-Chirurgical Society in 1891. At that time I held 
that the direct risks of the treatment were much overrated, 
more especially the risk of acute tuberculosis, and I still think 
that this is the case. In none of the cases in which I have 
used tuberculin, some sixty in number, did acute tuberculosis 
occur, while curiously enough three out of nine cases in which 
I was consulted on, or considered the advisability of using 
tuberculin, but decided against it, died of acute tuberculosis, 
and one developed a joint trouble shortly after the question 
was considered. 

In my opinion the two great dangers in this treatment are 
(1) its use where there are septic suppurating cavities or 
surfaces, and (2) leaving it off too soon. As regards the first, 
the chief trouble lies partly in the increase in the inflammation 
as the result of the action of the tuberculin, and partly in 
the weakening of the tissue by this inflammation, thus enabling 
the pyogenic organisms to penetrate further and more rapidly. 
As regards the danger of leaving the treatment off at an early 
period, it certainly is the fact that under such circumstances 
recurrence rapidly takes place, and in my experience the disease 
seems to progress with greater rapidity than before the treat- 
ment was employed. I am not sure that I can say the same 
where the treatment has been continued for some months and 
then left off. At any rate, speaking of lupus, while under 
these circumstances it has come back in places pretty quickly 
at first, it has afterwards seemed in several cases to come then 
more or less to a standstill, or even to improve somewhat. 
Certainly in several of the cases the condition of the patient 

11 



162 TREATMENT OF TUBERCULAR DISEASE. 

some months after the treatment was stopped, has not been 
so bad as before it was commenced, nor so bad as it seemed 
likely to become when recurrence first began to take place. 

As to the remedial powers of tuberculin there can be no 
doubt that in many cases where the conditions are favourable, 
as in lupus and tuberculosis on a free surface, a certain amount 
of remedial effect follows its use, which, however, but rarely ends 
in a cure of the whole area within a reasonable time. In only 
three of my cases where no operation was performed has the 
improvement been complete over the whole surface, and lasting 
after the treatment was stopped. These were two children 
with synovial disease of the knee-joint and one patient with 
phthisis. In all three cases the treatment was continued 
for about five months, and these patients remain well. Four 
other cases where sinuses were present which healed at the 
time also remain healed. In all the others in which the 
treatment has been stopped recurrence has taken place, but in 
the case of lupus, where one can see what occurs, this recurrence 
has not as a rule taken place over the whole of the previously 
affected area. In several bad cases of lupus considerable tracts 
have remained free, though in other parts the recurrence has 
been rapid and extensive. This shows that tuberculin has 
really the power of causing the permanent disappearance of 
tubercular tissue under certain conditions, and, from the 
microscopical appearances, I conclude that the main condition 
is that the tubercles shall be isolated and not aggregated into 
masses. Isolated tubercles seem to be readily infiltrated with 
inflammatory cells and disappear, while only the external 
portions of tubercular masses are in relation with the blood 
stream. As it is very rarely that in the tubercular area there 
are only isolated tubercles, or very small groups of them, it is 
very seldom that a complete cure will occur, at any rate within 
a short time. 

Although, however, larger masses are not destroyed by 
tuberculin their growth is brought to a standstill, for a time 



BENZOATE OF SODA. 163 

at any rate, and the question is for how long this condition of 
standstill can be kept up. This seems to vary very much in 
different cases, but on the whole, when the injections are given 
frequently in the manner which I recommended in my paper, 
I think that the disease may, in a good many cases, be kept 
in check for a long time. In only two of my cases are the 
patients still going on with the treatment — viz., in two doctors 
with phthisis, and these patients, though very ill and rapidly 
going down hill when the treatment was commenced, quickly 
picked up, even though staying in London during thick and 
very foggy weather, and have now for a considerable time been 
at work as surgeons on board steamers, with practically no 
symptoms of disease. They inject themselves every day, or 
every other day, and if they follow my advice will continue to 
do so indefinitely. On the whole, I think, considering the 
danger of leaving off the treatment too early and the length 
of time that it must be employed, that it does not come into 
play in those cases of external tuberculosis which are accessible 
to other local measures. On the other hand, in phthisis, I think 
that the treatment has been unduly discredited and too hastily 
abandoned, and in some cases of surgical tuberculosis where 
little else can be done, as in the case of bladder tuberculosis, 
the use of tuberculin, or of one of its constituents, may be 
of service in retarding the progress of the disease. 

I have already referred to the alteration of the chemical con- 
stitution of the fluid of the tissues by means of diet, &c, and this 
might also be done by other substances. I have attempted to carry 
out the idea of loading the tissues with soda, by resorting to 
the benzoate of soda, which formerly had a short-lived reputa- 
tion as a specific against tuberculosis. Formerly it was used 
on the view that it had a direct destructive action on the 
tubercle bacillus. I have, however, used it with the view of 
saturating the tissues with soda in the hope of rendering them 
an unsuitable soil for the bacillus, and for this purpose have 



164 TREATMENT OF TUBERCULAR DISEASE. 

administered the drug in doses of 20 grains every two hours 
night and day. In several cases improvement seemed to follow 
immediately on commencing this treatment, but in the great 
majority no apparent effect was produced. I have not, there- 
fore, thought it worth while to continue the use of this drug, 
but I believe that something might be done by trying to saturate 
the tissues with substances, non-poisonous in themselves, but 
when in excess inhibitory as regards the growth of the tubercle 
bacillus. 

Substances have also been employed locally, not with the 
view of destroying the tubercle bacillus, but with the view 
of acting on the tubercular tissue. For example, Koliseher 
published a method of treatment by injections of neutral 
phosphate of calcium into numerous parts of tubercular 
synovial membrane, with the view of causing calcification of 
the tubercle, and as has often happened in the history of 
these new remedies for tuberculosis, his first results seemed 
to be so good that he was quite enthusiastic in the matter, 
but in a later paper he confesses that his further results have 
not come up to his expectations, and he mentions so many 
circumstances under which his treatment will not be successful, 
that apparently very few cases are left in which it is likely to 
be of any value. The injections cause great pain, and not 
uncommonly gangrene of the tissues, and I do not think that 
the method is one to be recommended. Again, Lannelongue 
last year stated that he had had good results by injecting 
chloride of zinc into the tissues around the tubercular mass, 
with the view of causing encapsulation, but although I have 
the greatest respect for Lannelongue's opinion in the matter of 
surgical tubercular diseases, I cannot think that this is a method 
which is likely to lead to a satisfactory result. 



CHAPTER XIII. 

TREATMENT OF TUBERCULAR DISEASE OF BOXES 
AND JOINTS— Continued. 

Methods which act directly on the Tubercular Tissue — 
Various Injections — General Considerations influen- 
cing the Question of Expectant versus Operative 
Treatment. 

I must now pass to the consideration of the methods which 
act directly on the tubercular tissue and the tubercle bacilli, 
and these are of two kinds, viz. : — 1. The use of substances 
which are supposed to destroy the bacilli ; and 2. The removal 
of the affected parts by operation. 

A variety of substances have been used, both generally and 
locally, with the view of interfering with the growth of the 
bacilli, but so far without any special advantage. Various anti- 
septics have been injected into the tubercular tissue with the view 
of destroying the bacilli, for example, carbolic acid, creasote, 
guaiacol, &c, but these substances have failed in their object, 
and only irritate and weaken the tissues and enable the bacilli 
to spread. Thus Celli and Guarneri found that animals kept in 
cages and exposed to dry, finely powdered tubercular sputum did 
not necessarily become tubercular, but if their air passages were 
injured, among other things by inhalations of sulphurous acid, 
a certain number became affected with the disease. Again, 
Sormain and Pellicarni administered creasote inhalations to 
rabbits which had been previously made tuberculous, and found 
that not only was tuberculosis of the lungs not prevented, but 
that the lung disease was actually worse in these animals than 
in others which had not been so treated. The only one of the 



166 TREATMENT OF TUBERCULAR DISEASE. 

substances which has been recommended to which I need refer 
is iodoform. 

There has been much controversy as to the anti-parasitic 
effect of iodoform and its mode of action, and the question is 
still far from settled. Certainly no anti-parasitic effect can be 
produced outside the body; organisms grow, though perhaps 
more slowly, on soil thoroughly impregnated with iodoform, for 
instance, on the surface of potatoes thickly covered with the 
powder, while if tubercle bacilli are thoroughly mixed up with 
iodoform and introduced under the skin of a guinea-pig tuber- 
culosis will still result. Indeed, septic infection has occurred 
in wounds, in several instances, from powdering them with dry 
iodoform, and this is one of the things to be guarded against in 
the use of this substance. Hence in an operation performed 
with unbroken skin iodoform cannot be recommended as an 
antiseptic with the view of preventing septic infection; this 
is certainly my experience, both in my own work and .in what 
I have seen of the work of others. And yet if it is employed as 
an application to a putrid suppurating sore the smell very soon 
disappears and the suppuration diminishes. As an explanation 
of this fact it has been stated that, while pyogenic organisms 
grow in material containing iodoform, their poisonous products 
are apparently decomposed as soon as they are produced, and 
this decomposition of the bacterial products is accompanied by 
breaking up of the iodoform, and it is possible that the iodine 
thus liberated may act to a certain extent destructively, on the 
bacteria. Whether that be so or not the destruction of the 
bacterial products deprives the bacteria of their weapons, 
without which they cannot do much harm, and they are then 
more rapidly destroyed by the tissues. And thus it may really 
be of service in tuberculosis not so much by destroying the 
bacillus as by breaking up its products and thus rendering it 
more or less incapable of doing harm. It has recently been 
pointed out by Krause that iodoform acts better in closed 
cavities away from the air, as in abscesses, than on a free 



EXPECTANT VERSUS OPERATIVE TREATMENT. 167 

surface, and that better results will be obtained in open tuber- 
cular wounds by packing them well with gauze saturated with 
iodoform than by sprinkling the iodoform on the free surface. 
Certainly I have had several cases lately, which seem to confirm 
this view, where tubercular sinuses have done very well by 
slitting them up and stuffing them with iodoform gauze, 
better than by the former plans of scraping and draining them 
or injecting iodoform and glycerine. 

We next come to the consideration of the various operative 
measures by means of which the tubercular tissue is more or 
less completely removed. I must, in the first instance, say a 
few words as to the kind of cases in which expectant treatment 
is likely to prove successful, and those in which operation is 
desirable, but I need not go at any length into this question as 
I discussed it in a paper read at the Harveian Society in 1890, 
and published in the Lancet in October of that year. I need 
only indicate some of the points which influence our decision. 
Two points which exercise great influence in the minds of 
surgeons as regards this matter are the views which they hold 
as regards the curability of the disease by expectant means 
and the danger of infection of the body from the local focus. 
I have already discussed the question of the curability of the 
disease, and we have seen that, in many cases, the tubercle bacilli 
have difficulty in making headway against the body, and that 
very little will sometimes turn the scale in favour of recovery. 
Speaking generally I do not think that we ought to take the 
very gloomy view as regards the prognosis of surgical tuber- 
culosis which is held by some to whom the diagnosis, tuberculosis, 
at once suggests an extremely grave prognosis and a great 
necessity for radical operative interference. The prognosis does 
not so much depend on the general views as to the curability of 
the disease as on the local condition of the individual case, and 
its tractability or intractability to treatment. 

Another point which is hot without influence is the question 



168 TREATMENT OF TUBERCULAR DISEASE. 

whether and how far the presence of a local deposit is a source 
of danger to the body generally, and to what extent operative 
interference will prevent that danger. It is, of course, clear 
that the presence of an active tubercular deposit must be a 
source of danger to the body generally, seeing the great ten- 
dency of the tubercular virus to get into the lymphatic or blood- 
vessels, and that the thorough removal of the tubercular deposit 
will remove a source of infection. But in the case of joint 
disease it does not by any means follow that the removal of 
that disease will save the patient from fresh tubercular deposit, 
or can do more than remove one source of infection. For it 
must be remembered that it is only very rarely that the joint 
trouble is the primary tubercular lesion, most usually it is 
secondary to tuberculosis elsewhere, more especially in the 
bronchial glands, and although the joint trouble is completely 
removed, the further development of tubercle in other parts 
may still take place from another focus. The question must 
also be looked at from another point of view — viz., may not the 
operation itself lead to dissemination of the disease. This only 
applies to such procedures as amputation through the affected 
parts, excision, arthrectomy, or partial operations, such as scrap- 
ing ; by amputation above the affected part there is no reason 
to suppose that any dissemination can occur. There certainly 
seems some ground for believing that partial operations can 
lead to dissemination of the disease, and that, far from saving 
the patient from further disease, they may lead to further 
infection. Thus, as regards acute tuberculosis, it seems, now, 
to be the experience of several surgeons that it occurs most 
frequently in cases that have been operated on. Thus Konig 
states that, of eighteen cases of acute tuberculosis in his practice, 
sixteen occurred after operation, and in the statistics I have put 
together we have a record of seven cases after operation, two 
at least being, I think, directly caused by it. 

Wartniann, in a large number of cases, found that, after 
excision, 10 per cent, died of acute general tuberculosis, many 



TUBERCULOSIS AFTER OPERATION. 169 

of the cases being apparently directly due to the operation. Of 
course it must be remembered, with regard to all statistics of 
excision, that, up till quite recently, excision was only a very 
partial operation as regards removal of the disease, and stat- 
istics, based on excisions as formerly performed, are no answer 
to the proposition that the removal of the disease will diminish 
the risk of general infection. I know of no statistics embrac- 
ing a sufficient number of cases where the results of amputation 
above the affected part, or of really complete arthrectomies or 
excisions, are given, and I can only say that as regards my 
own recent cases, while I have, I think, twice lost patients from 
tubercular meningitis after partial operations, I have had no 
case of the kind after complete ones. It seems to me to stand 
to reason that complete removal of the disease by cutting be- 
yond it, not by scraping or gouging, cannot cause any real risk 
of dissemination of the disease, while, on the other hand, it can 
only rid the patient of one source of infection, leaving him, 
however, exposed to the occurrence of dissemination from the 
original focus. 

As regards phthisis, also, while some cases may be arrested 
by early and radical operation, others may be precipitated 
by partial operation. Thus Middeldorpf found that, after 12-J- 
years, 16 per cent, of those amputated (whether through or 
above the diseased part is not stated) had died of tuberculosis, 
14 per cent, of those excised, and 30 per cent, of those where 
caseous deposits were scraped out. Hence, except in the case 
of existing phthisis, I do not think that the hope of preventing 
the extension of the disease need influence us to a large extent 
in deciding on operation as against expectant treatment. But 
in a case where the decision is doubtful, this danger may be 
allowed to turn the scale in favour of operation. On the other 
hand, in deciding what operation should be done, where the 
patient is highly predisposed and likely to develop tuberculosis 
elsewhere, the danger of partial operations must be borne in 
mind, and the decision given in favour of radical measures. 



170 TREATMENT OF TUBERCULAR DISEASE. 

The age of the patient influences, also, the question in that 
the chances of recovery without operation are greater in the 
young than in the old, that synovial disease, the most 
favourable form, is more frequent, that certain operative pro- 
cedures, such as excision, are practically prohibited, &c. The 
existence of marked hereditary taint or of phthisis or tuber- 
culosis elsewhere is also of importance, seeing that they are 
often aggravated by the local disease, especially if sinuses are 
present, and are, vice versd, often much benefited by complete 
removal of the local affection. 

The most important point in coming to a decision as to the 
question of operation is the local condition of the part, more 
especially the extent of the disease, the signs as to recovery or 
otherwise, and the conclusion arrived at as to the possibility 
of recovery by expectant means. In the first place, we can 
at once divide tubercular diseases into two great groups 
— viz., those in which chronic abscess has formed, and those in 
which there is as yet no noticeable breaking down of the tuber- 
cular deposit. Cases in which chronic suppuration has taken 
place are at once excluded from purely expectant treatment, 
because operative treatment of the abscess at least must be 
carried out ; what that operative treatment should be we shall 
presently consider. Excluding cases in which suppuration has 
occurred, we have to consider in which of the remaining cases 
operative interference is indicated, and in which it is desirable 
to continue expectant treatment. I have pointed out in the 
former chapters that the joint disease frequently begins at one 
part either of the bone or of the synovial membrane, and that 
it spreads from that part over the rest of the joint. Hence we 
meet with two conditions at an early stage of the disease — viz., 
either diffuse involvement of the whole structures of the joint, 
or a limited disease of the bone or synovial membrane, the 
latter usually in the form of polypoid tubercular masses, as 
described by Konig, but sometimes in the form of limited 
thickening of the synovial membrane. Where such cases are 



EXPECTANT VERSUS OPERATIVE TREATMENT. 171 

seen and recognised in the early stages, it may be possible to cut 
short the disease by early operation, performed with the view 
of removing the diseased tissue alone. Hence such cases come 
under the head of those requiring operative interference. This 
leaves us with cases of general disease of the joint without 
suppuration, which may be of several kinds — viz., primary 
synovial thickening, without affection of cartilages or bone ; 
primary synovial disease, with destruction of cartilage and 
caries of the surface of the bone ; synovial thickening, 
secondary to an osseous deposit, with or without caries ; and, 
lastly, these conditions combined, with serious deformity. Of 
these cases, a cure is least likely to be obtained by means 
short of operation where a deposit is present in the bone, and 
in cases where the situation of the deposit is known, and 
where it is easily accessible, as in the olecranon, condyles of 
the femur, &c., it is often advisable to operate early, at any 
rate if the disease is progressing. 

The best cases for expectant treatment are those of pure 
synovial disease without destruction of cartilage, especially 
where the thickening is not very marked and is pretty firm, 
and in children expectant treatment should be employed in the 
first instance in all cases of diffuse synovial disease, and also for 
a time, at any rate, where caries of the bone is present, and 
should be persevered in so long as the disease does not progress, 
or other circumstances do not arise necessitating operation. 

The presence of marked deformity, the question as to which 
method of treatment will give the most useful result ultimately, 
and also often the question which will be most speedy, influence 
our decision in many cases. 

I may sum up as follows : — Operative treatment is desirable 
in the following cases : where chronic suppuration has occurred ; 
at an early stage where the disease is localised to one part of the 
synovial membrane or bone ; in many cases, at a later stage 
where there is a deposit in the bone along with general synovial 
thickening; in cases of diffuse synovial thickening where 



172 TREATMENT OF TUBERCULAR DISEASE. 

expectant treatment has failed to arrest the progress of the 
disease ; in cases where a better functional result can be obtained 
by operation ; in cases in adults where deformities are present, 
which can only be remedied by operation ; in many cases where 
there are septic sinuses ; in certain cases where phthisis is 
present, or where the general condition is such as to require 
removal of the disease ; in adults more frequently than in 
children ; in the poor more often than in the rich. Expectant 
treatment should be employed, in the first instance, in cases of 
diffuse synovial disease without suppuration, provided that there 
are no reasons requiring immediate operative interference, and 
it should be persevered in for a long time ; also at first in cases in 
children where osseous deposits are present in parts where they 
cannot be reached without excision ; and in some cases where 
septic sinuses are present. Much depends, also, on the joint 
which is the seat of disease, for example, in the case of the hip 
joint expectant treatment should be much longer persevered 
in than in a more superficial and easily accessible joint. 



CHAPTER XIV. 

GENERAL PRINCIPLES OF TREATMENT. 
Choice of Operation. 

The modes of complete removal of the disease in cases of tuber- 
cular joint disease are three in number, viz. — 1. Complete 
removal of the diseased tissues, along with as little as possible 
of the healthy structures ; what is understood by the term 
" arthrectomy " ; 2. removal of the diseased tissue along with 
certain portions of the ends of the bones, whether diseased or 
not, that is to say, excision; and 3. amputation above the 
affected joint. I have already referred to another operative 
measure, viz., arthrotomy and intermediate between it and com- 
plete arthrectomy, is partial arthrectomy, where portions of the 
diseased tissues only are removed, parts being left behind inten- 
tionally. I may say with regard to simple arthrotomy that it 
seems to me that if once a joint is freely opened, we may as well 
try to take away at least as much of the disease as we can with- 
out disadvantage, and therefore in cases where I would formerly 
have performed arthrotomy, I have usually of late done a partial 
arthrectomy, thus combining the principle of removal of the 
diseased tissue with that on which we suppose that arthotomy 
acts, viz., relief of tension, and consequent diminution of the 
inflammation. 

We must now consider the relative advantages and disadvan- 
tages of these methods of treatment, and the principles which 
guide us in making our choice. Many circumstances influence 
our choice of the operative measure, and of these I may refer to 
three, viz., the influence of age, of the general condition of the 
patient, and of the local condition. 



174 GENERAL PRINCIPLES OF TREATMENT. 

Taking first the influence which the local condition exerts on 
the operative procedures, we may consider it — 1st, as to the 
influence of chronic suppuration : 2nd, as to asepsis ; and 3rd, 
as to the distribution and character of the local disease. 

The occurrence of chronic suppuration in connection with 
tubercular diseases of bones and joints greatly increases the 
gravity of the case, and exercises an important influence on the 
question of treatment. It usually indicates a progressive form 
of the disease, while the opening of the abscesses if large, and if 
not performed aseptically, exposes the patient to very great 
dangers in consequence of the resulting decomposition of the 
contents and septic inflammation of the wall. So impressed are 
some surgeons with the unfavourable character of these cases 
that they recommend the most radical operations (excision or 
amputation) in cases where suppuration has occurred. For 
example, Konig states that in the case of abscesses connected 
with tubercular disease of bones and joints, drainage is practi- 
cally never sufficient, and he limits the drainage of abscesses to 
those connected with the atrophic form of the disease (caries 
sicca), and to some cases in children. I suspect that this opinion 
must be founded on imperfect asepsis of the wounds, for though 
no doubt the occurrence of suppuration greatly complicates the 
case, much can be done in many cases by less severe procedures 
than excision or amputation. Thus, if we take the case of 
spinal abscesses, where one must persevere to the end without 
the possibility of complete removal of the disease, I found some 
years ago, in Sir Joseph Lister's practice and my own, a record 
of 58 cases of spinal disease with abscess, in patients of various 
ages, but mostly adults, and of these 38, or over 65 per cent., 
had been cured by aseptic drainage, and several were under 
treatment. Of these 58 cases, however, 9 had become septic 
from one cause or another, and as in these another very import- 
ant factor, viz., sepsis, is introduced, we obtain the true effect of 
chronic suppuration by omitting them, and thus we are left with 
49 cases, of which 38, or 77"5 per cent., were cured, 6 were going 



INFLUENCE OF CHRONIC SUPPURATION. 175 

on well, but had not yet healed, and 5, or 13-1 per cent., had 
died. Several of these cases had more than one abscess. In 
these cases nothing was done in the way of operative interfer- 
ence, except to open the abscesses, and hence it follows that a 
chronic abscess in connection with bone disease is not such a 
hopeless thing as is supposed by some. In the case of joints we 
are not restricted to drainage of abscesses, but can often hasten 
the cure by various operative measures ; hence the results are 
not so striking, because if healing did not occur pretty soon, 
something more was done. Now, omitting the spinal abscesses, 
we had 105 cases in which chronic suppuration was present in 
connection with the six larger joints ; in 37 of these, excision or 
amputation, were ultimately performed, leaving 68 cases in 42 
of which drainage alone was employed, in 18 partial arthrectomy, 
and in 8 simple arthrotomy. Of these 68 cases, in which no 
radical operation was performed, 50, or 73'5 per cent., had healed 
when the statistics were made up, and only 3, or 4'4 per cent., 
had died, all of tubercular disease elsewhere. We thus see that 
although the occurrence of chronic suppuration undoubtedly 
increases the gravity of the cases, and implies a graver form of 
the disease, there is no absolute necessity for performing a 
serious operation such as excision or amputation at once, just 
because suppuration has occurred. At the same time, consider- 
ing the length of time that is required for healing when aseptic 
drainage is employed, on an average eight to twelve months, the 
probability that caseation is going on elsewhere, and all the 
facts of the case, I believe it is best in most instances to treat 
these cases in a more radical fashion. 

A chronic abscess is, as I showed in Chapter VII., nothing 
more or less than a tubercular tumour with softened centre, 
and therefore no treatment is complete in which an attempt is 
not made to remove the wall. By simply opening and draining 
a chronic abscess, the essential part of the disease, the wall, is 
left untouched, and the main curative work has to be done 
by nature. The first outcome of this more exact pathology was 



176 GENERAL PRINCIPLES OF TREATMENT. 

the attempt, after removal of the contents of these abscesses, to 
apply some bactericide to the wall, and as at that time iodoform 
was much thought of as an anti-tubercular agent that was the 
substance chosen. Mickulicz was the first to act on the recent 
pathology, and his plan was to introduce a trocar into the 
abscess cavity, evacuate the fluid contents, wash out the cavity 
with weak carbolic lotion till the fluid returned clear, inject a 
10 per cent, emulsion of iodoform in olive oil and glycerine and 
stitch up the puncture. This method was taken up enthusi- 
astically by several surgeons in Germany, notably by Billroth 
and Von Bruns, and also in France where a modification was 
made in that an ethereal solution of iodoform was substituted 
for the emulsion. The results of this method of treatment are 
fairly good, but in most cases either the puncture wound breaks 
down and a sinus forms which is some time in healing, or the 
fluid reaccumulates and the performance has to be repeated, 
sometimes several times. Since these first attempts to act in 
accordance with the pathology of the disease, it has become 
generally recognised that some more energetic treatment of the 
wall of the abscess was desirable, and there are three ways in 
which this can be carried out. 

1. The most radical and satisfactory method is to dissect out 
the swelling, without opening it, as if it were a cyst. This 
can be done in many cases, for example, in most glandular 
abscesses, in the subcutaneous tubercular nodules of children 
(gommes scrofuleuses), in many abscesses connected with the 
ribs, in some connected with bones, &c. Where this is done a 
clean cut wound is left which heals by first intention. 

2. If the abscess is too large or the connections such that it 
cannot be dissected out in this way, the next best thing is to 
lay it freely open so as to see its interior, and then remove the 
wall by clipping, cutting, &c. This is possible in a good many 
cases of abscesses, especially in the extremities, and in this way 
again we can often get a healthy wound which heals by first 
intention. 



TREATMENT OF CHRONIC ABSCESS. 177 

3. Failing either of these two methods we can still get rid 
of the greater part of the wall by making a smaller incision 
into the abscess, scraping away the wall by a spoon, or rubbing 
off the degenerated tissue by means of rough sponges, &c. The 
following is the best plan to adopt where only a small opening 
can be made into the sac. The necessary antiseptic precautions 
are, of course, taken, and a small incision is made into the 
abscess, somewhat larger than can admit the finger, which is 
then introduced, and the cavity thoroughly explored to ascertain 
its connections, &c, and any septa present in it broken down. 
A sharp spoon is then introduced, preferably one of Mr. 
Barker's flushing spoons, and the surface of the abscess wall is 
gently and thoroughly scraped, free exit being allowed for 
the fluid ; I believe that it is well to introduce the finger from 
time to time and guide the spoon to fresh parts of the wall. 
Where scraping is dangerous, as towards the peritoneum or 
along a large vein, a good deal of the degenerating material 
can be removed by introducing a piece of coarse sponge into 
the cavity and rubbing the surface with it. Any loose piece 
of bone is removed or carious bone scraped or gouged as 
thoroughly as possible. At the same time the cavity is 
thoroughly flushed out with warm 1-10,000 sublimate solution, 
the excess of fluid is squeezed out, 1 to 2 ozs. of a 10 per cent, 
emulsion of iodoform in glycerine, containing a small propor- 
tion of sublimate is injected, allowing as much to remain in 
as will do so, and the wound in the skin and deeper parts 
stitched up. This is the plan which must be adopted in 
some large and deeply seated abscesses, especially in psoas 
and iliac abscesses. In a good many cases the wound 
heals by first intention and remains healed, in others a 
sinus may form and remain open for a few weeks, or 
may even necessitate a repetition of the performance. I 
have always looked on the injection of the iodoform as of 
doubtful value, and have in several cases omitted it : I am 
inclined on the whole, however, to think that the cases in 

12 



17S GENERAL PRINCIPLES OF TREATMENT. 

which it has been employed have done better than the 
others. 

This method, while on the whole very satisfactory, is never- 
theless not unattended with risk in the case of large abscesses, 
especially of large psoas abscesses, the danger being from shock 
or from haemorrhage. 

Applying these methods to diseases of joints the treatment of 
chronic suppuration in connection with joint disease, and the 
influence which it will exert on further operative measures, will 
depend on the relations of the pus and the -general extent of 
the disease. As examples I may mention the following : — 

1. The abscess may be unconnected with the joint at all, 
having formed in connection with a tubercular deposit in the 
bone which has reached the surface outside the joint, and there 
may be no thickening of the synovial membrane. Under such 
circumstances where the connections are such as to render it 
possible, the best treatment is to dissect out the abscess and 
remove the bone deposit. Where it is impracticable to dissect 
out the abscess the second method should be employed. 

2. A similar condition may be present with, in addition, 
thickening of the synovial membrane. Here, so far as regards 
the abscess and the osseous deposit, the treatment may be the 
same as in No. 1. Whether anything further might be required 
on account of the synovial thickening will depend on the 
local condition, and on various circumstances which cannot be 
reduced to rule, some of which will be alluded to presently. 

3. The abscess may have originated in connection with the 
synovial membrane, and may or may not communicate with the 
joint. In such a case we generally find caseous patches in 
other parts of the synovial membrane, and though, from our 
experience with aseptic drainage, it is clearly possible to get a 
good result, in some cases, without any radical operation, I 
believe it is on the whole best, in most cases, to look on the 
presence of such an abscess as an indication for complete 
removal of the diseased tissues, either by excising the abscess 



TREATMENT OF CHRONIC ABSCESS. 179 

wall and complete arthrectomy in children, or excision or 
amputation in adults. This rule holds good in most cases of 
disease of the knee, elbow, and ankle joints ; in the case of the hip 
and shoulder, however, I should, in a good many cases, be 
content with treating the abscess in the 2nd or 3rd way, 
removing only so much of the diseased tissues as was easily 
accessible in the first instance, unless there was some special 
reason for performing a more radical operation at once. 

The same rule, I believe, applies to the wrist joint, and also, 
to some extent, to the tarsus, though, in the latter, where one 
of the bones is primarily diseased, it is often possible, at the 
early stage, to get rid of the disease by removal of the affected 
bone and synovial membrane. 

4 Where the pus is only present in the interior of the joint, 
and the patient is young, the joint should be laid freely open 
and search made for osseous deposits. If such deposits are 
found, they must be removed and complete synovial arthrec- 
tomy performed. In adults, however, excision, with thorough 
removal of the synovial membrane, is the best practice, unless 
the bone is so extensively diseased or the other conditions such 
that amputation seems desirable. Here, again, the decision 
must vary with the joint affected. 

5. Where we have both pus in the joint and abscesses around 
it, we have usually to choose between excision and amputation, 
and in adults, considering the length and extent of the operation 
of excision in such cases, amputation is, as a rule, the better 
practice. In some cases in children, however, it may be well 
to see, in the first instance, what can be done by as thorough 
removal of the tubercular tissues as possible, persevering in the 
treatment so long as the wound remains aseptic and the general 
health does not suffer. 

Another very important factor which influences our decision 
as to the kind of operation, is the aseptic or septic condition of 
the part. The presence of sepsis aids, as I have previously 
shown, the spread of the tubercular disease, thus reducing the 



180 GENERAL PRINCIPLES OF TREATMENT. 

chances of recovery by expectant means ; hence it often neces- 
sitates the employment of more severe operative procedures 
than would otherwise be necessary with the view of effecting 
a cure. Anything which depresses the vitality of a part aids 
the progress of the tubercular disease, and septicity is a very 
powerful agent in depressing vitality. Accordingly, we find 
that where septic sinuses are present the disease is much more 
stubborn, and the chances of cure without severe operative 
measures are much less than where the skin is unbroken when 
the case comes under treatment. Thus, to mention only one 
fact, the results at the hospital for hip disease published in the 
" Transactions of the Clinical Society " in 1881, were, as far as 
I understand, obtained in cases with septic sinuses. Of these, 
the certain cures by expectant treatment were 32'8 per cent. ; 
and the deaths, 33"5 per cent. In our much smaller number 
of hip-joint abscesses treated by aseptic drainage, 25 in all, 
that is to say in cases with aseptic sinuses, the certain cures 
were 72 per cent, and the deaths 4 per cent. 

Apart also from the fact that when sepsis is present there is 
much less likelihood of getting a cure without further operative 
measures, sepsis also increases the risk of dissemination of the 
disease, and thus increases the necessity for early and radical 
measures. I have already, in Chapter IX., pointed out the 
more frequent occurrence of tubercular meningitis, and of 
phthisis, in septic cases as the result of the depression of the 
tissues locally and generally, and also the risk of re-inocula- 
tion of the wound with tubercle after partial operations in 
septic cases, and I need not repeat what I have already said. 

Further, the presence of septic sinuses influences the operative 
treatment, not merely by rendering the disease more stubborn, 
but also by introducing the risk of the various septic diseases. 
It is not always possible to eradicate the septic element during 
an operation, and hence, in cases of septic sinuses in connection 
with pure synovial disease, and not leading into the joint, and 
where the cartilage is still intact, it is always questionable 



INFLUENCE OF SEPSIS. 181 

whether we can safely perform synovial arthrectomy or not 
on account of the risk of acute suppuration of the joint. And 
even if. the case is one where complete excision would, in any 
case, be necessary, the presence of sepsis greatly increases the 
risk of the operation, making it decidedly greater than amputa- 
tion above the seat of disease. 

Hence, in treating a case of tubercular joint disease with septic 
sinuses, it is, I think, advisable in most cases, to do more than 
merely put the part at rest, some operative treatment must, as a 
rule, be adopted. Where it is not deemed desirable to proceed 
to radical measures, I believe the best treatment is to lay the 
sinuses freely open, scrape or clip away their walls, remove as 
far as possible the starting-point of the original abscess, whether 
in bone or in synovial membrane, sponge the surface of the wound 
with undiluted carbolic acid, stuff the wound with iodoform 
gauze or cyanide gauze freely sprinkled with iodoform, and allow 
it to granulate from the bottom. My experience is most 
distinctly that much better results are obtained in this way 
than by simply enlarging and scraping out the sinuses and 
inserting a drainage tube, as was the method formerly employed. 
As I have previously mentioned, Krause is of opinion that 
iodoform is more active where oxygen is absent than where it 
is present, and by stuffing a wound there will certainly be less 
oxygen in it than where a drainage tube is employed. However 
this may be, I can only say that since I took to treating septic 
tubercular sinuses in this way my results as regards healing 
have very much improved. In cases of joint disease, however, 
this plan is only applicable to cases where the disease is not 
very marked nor rapidly progressive, and where there are only 
one or two sinuses. Where the sinuses lead into the joiut, or 
are multiple, or where the disease is advancing, one of the 
three radical measures previously referred to should, I think, be 
adopted in most cases, the choice depending chiefly on the age 
and general condition of the patient, and on the local condition. 
At one time I was inclined to think that the presence of septic 



182 GENERAL PRINCIPLES OF TREATMENT. 

sinuses excluded arthrectomy, but I have now done several 
complete arthrectomies in such cases, sponging the surface of 
the wound afterwards with undiluted carbolic acid, and with 
good results. 

Of the cases where the skin is unbroken when the patients 
come under observation, and where no suppuration is present, 
we have a group where the disease of the bone or synovial 
membrane is limited to one part of the joint, the rest of the 
structures being healthy. These are the cases which are 
especially suitable for arthrectomy, though unfortunately it is 
not always easy to diagnose the osseous lesions in the early 
stage, nor is it often that one sees the patient before the whole 
joint has become affected. In these cases the foci of the disease 
can usually be completely removed without seriously interfering 
with the function of the joint, indeed, with the result that the 
function of the joint is restored. I may mention three instances 
by way of illustration : — 

1. In the first case, a boy cet. 5, the disease in connection 
with the elbow-joint began after a fall about a month before 
admission. The external condyle of the humerus was con- 
siderably thickened, and there was a distinct diminution in the 
resonance of the percussion note at one part. There was no 
pain, and no thickening of the synovial membrane. An incision 
was made over the back of the external condyle, the periosteum 
was turned aside, and a portion of the bone, which was in part 
unossified, was gouged away ; a small collection of soft material 
showing tubercular structure on section was found and removed ; 
the surface was sponged with pure carbolic acid, and the wound 
closed. During the operation the joint was opened, but was 
quite healthy. The wound healed by first intention, except at 
one point left open to allow escape of blood, and this soon 
healed, and the result was perfect restoration of the joint and 
eradication of the disease. 

2. A little girl, aged 3, was admitted with a swelling on the 
outer and back part of the elbow, which had been noticed for 



ARTHRECTOMY. 183 

four months. There was a soft swelling the size of a small 
marble over the head of the radius, and slight puffiness of the 
synovial membrane around this nodule, but not elsewhere, and 
some limitation of movement, especially of rotation. An incision 
was made over this swelling, and it was dissected out along 
with a considerable area of the synovial membrane around ; it 
was found to consist of thickened synovial membrane containing 
tubercles, and in its interior there were a few drops of semi- 
purulent fluid. The disease extended to the synovial membrane 
under the orbicular ligament, and this was thoroughly dissected 
away ; the rest of the joint was healthy. The wound healed by 
first intention, and there was complete recovery of the joint. 

3. Boy, cet. 7, admitted with pain and rigidity about right hip 
for three months, complete limitation of movement, great 
thickening of the great trochanter and neck of the femur, 
apparently no thickening of the synovial- membrane, no flexion 
or shortening, no thickening on the inner wall of the acetabulum. 
It was evident that there was a tubercular deposit in the neck 
of the femur, which had probably not yet opened into the hip- 
joint. I therefore made an incision over the outer part of the 
trochanter, trephined through the dense bone, and then scooped 
out the neck of the bone till a cheesy mass was reached, 
apparently not far from the epiphysial line. The wound was 
sponged out with undiluted carbolic acid and left open. It 
took nearly six months to close finally, showing that I had not 
succeeded in getting out all the disease, but the free opening 
probably prevented further extension to the joint. When I last 
saw him about three years later, there was a considerable amount 
of movement in the joint, and apparently no disease. 

Arthrectomy is also the proper treatment for those cases 
of pedunculated tubercular growths from the synovial mem- 
brane, which have been described by Konig, Eiedel, and others. 
Eiedel mentions two instances in which these growths have been 
removed with success, and in my statistics there is a record of 
one such case also successful. 



184 GENERAL PRINCIPLES OF TREATMENT. 

While it is self-evident that in these cases, with localised 
patches of disease, the removal of the affected tissue is the 
proper treatment, provided it is done aseptically, it is not 
so easy to come to a decision as to the nature of the 
operative treatment in cases where the disease is more 
diffuse, and which are evidently unsuitable for expectant 
treatment, or in which expectant treatment has failed. I have 
already referred to the treatment of cases where chronic sup- 
puration has taken place, and where we have either unopened 
abscesses or septic sinuses. In the remaining cases, where 
there is considerable diffuse thickening of the synovial mem- 
brane, with or without deposits in the bones, or caries of 
the surface, we have the choice of four methods of operative 
treatment, viz., arthrectomy, partial arthectomy, excision, and 
amputation. Before proceeding to discuss the advantages and 
disadvantages of the three radical methods of treatment, I must 
say a few words as to the advisability of performing partial 
operations, and as to whether partial arthrectomy, i.e., removal 
of only a part of the diseased tissues should have a place in 
our operative measures. In joints where subsequent mobility 
is wanted, such as the elbow, and possibly also the knee, a 
great objection to complete arthrectomy is that such a pro- 
cedure often involves removal of the fibrous capsule, and 
frequently of the ligaments, or at any rate their division, and 
consequently impaired strength and mobility of the joint. 
When I began to perform arthrectomies systematically I was 
of opinion that good results ought to be obtainable in a consider- 
able number of cases by only removing a portion of the disease 
without breaking up the joint, and I therefore did this in 
several cases. My reason for this view was the good results 
of expectant treatment, and the fact which I have been trying 
to point out, viz., that the tubercle bacillus often has a hard 
struggle for existence in the body, and that very little will 
sometimes turn the scale against it. This is exemplified by the 
results of arthrotomy, the actual cautery, aseptic drainage of 



PARTIAL ARTHRECTOMY. 185 

abscesses, &c. Further, in typical excision, as performed up 
till quite recently, no systematic attempt was rhade to remove 
all the diseased tissues, in fact the synovial membrane was 
often left behind, and yet healing occurred in a considerable 
number of cases, though here, it is true, fistula? frequently 
formed and remained open for a long time. In subperiosteal 
excisions it is of course impossible to remove all the diseased 
tissue, and yet this method sometimes yields good results, and 
is advocated by a good many surgeons. And in some excisions, 
especially in the case of the hip-joint, as performed at the 
present time, and even in some arthrectomies, scraping has to 
be resorted to as regards portions of the synovial membrane 
(quite an uncertain method as regards removal of the disease), 
and yet primary union after excision of the hip is the rule 
rather than the exception. Lastly, in several of the cases, in 
the statistics which I have been using, in addition to opening 
the joints, scraping or clipping away portions of tissue was 
employed, and in a considerable number with success. Thus 
nineteen cases of disease of the knee-joint were treated in this 
way, and of these thirteen were cured, or much improved, by 
the treatment, though in some of these a good many months 
elapsed before healing was complete. 

Since these statistics were made up, I have performed several 
partial arthrectomies, but I must confess that on the whole I 
am disappointed with the results obtained, and the conclusion 
I have come to is that this operation has only a very limited 
field, and that in most cases, where it becomes necessary to 
remove diseased tissue, complete removal is preferable. In a 
few cases, however, partial arthrectomy may be of use, especially 
where on cutting into the joint the synovial membrane is 
found not to be markedly pulpy, where the disease is in the 
substance of the membrane, not on its surface, and does not 
affect the bone, and where no cheesy spots are present. In 
other cases it is better to go on to complete removal of the 
affected tissues. 



CHAPTEK XV. 

AETHRECTOMY, EXCISION AND AMPUTATION IN 
JOINT DISEASE. 

Having determined to remove the disease completely the 
question arises which of the three radical operations — arthrec- 
tomy, excision, or amputation, should be performed. Of these 
I may dismiss the question of amputation in a few words, 
because no general rules can be laid down with regard to it. 
Amputation is the least dangerous of the three radical opera- 
tions, in fact, now-a-days no special danger is attached to it ; 
it is possible that here and there a weakly patient may succumb 
from shock after amputation high up in the thigh, but other- 
wise, if aseptically done, there is no danger. Hence, in weakly 
patients who cannot stand a prolonged operation, such as 
arthrectomy or excision, and where a radical operation is 
necessary, amputation is the best. So where phthisis is present, 
at any rate if it is advancing and the patient rapidly going 
down hill, amputation is best, indeed, it is sometimes remark- 
able what an improvement takes place in the condition of 
the patient and of the lungs after amputation through healthy 
tissues above the seat of the disease. Similarly in waxy 
disease of the kidneys, if radical operation is possible at all, 
amputation is the least dangerous. Again, in adults, and 
especially in old people, where there is much suppuration about 
the joint, or where septic sinuses are present, amputation is, 
in the majority of cases, the best practice. In the young also, 
where the disease is extensive, especially in the bone, amputa- 
tion may in some joints, such as the knee, be preferable to 
excision, and also where bad recurrence takes place after 
excision or arthrectomy, amputation may become necessary. 



COMPLETE ARTHRECTOMY. 187 

In fact, no definite rules can be laid down, the decision must 
be made in each case according to the local condition and the 
general state of the patient. I shall, therefore, pass on to the 
question of arthrectomy versus excision, and in the first place 
I may describe exactly what I mean by these operations. 

By arthrectomy I understand all operations by which the 
whole of the tubercular tissue is removed, with as little as 
possible of the surrounding healthy tissue. The term is not 
a good one any more than its substitute erasion, but as I am 
not an adept at coining words, I shall use it here in the sense 
which I have just defined. We may in reality perform a 
complete arthrectomy — i.e., complete removal of the disease 
without even cutting into the joint at all, or at any rate 
without removing any portion of the joint, for example, where 
tubercular deposits are present in the ends of the bones and 
have not yet burst into the joint, as in the bip-joint case I 
have previously mentioned, where I tunnelled through the 
neck of the femur, or in the elbow-joint case, where I removed 
a deposit from the condyle of the humerus. Again, as in the 
elbow-joint with the synovial disease limited to the outer side 
of the capsule, though the joint was cut into, only a portion 
of the synovial membrane was removed, and yet I group that 
case under the cases of complete arthrectomy, because as far 
as one could judge the disease was completely removed. I term 
the arthrectomy complete because the whole of the disease was 
removed, not because the whole of the structures of the joint 
was cut away. As a rule, however, in complete arthrectomy 
the operation is a very extensive one, and requires much 
patience and great care for its satisfactory performance. The 
whole diseased tissue must be removed by careful dissection; 
scraping is quite unsatisfactory, unless as regards small points, 
especially in the cartilage, and then it must be very thoroughly 
done. 

Let me describe a complete arthrectomy of the knee-joint 
where the whole synovial membrane is involved, as an example 



188 ARTHRECTOMY, EXCISION AND AMPUTATION. 

of the operation. The first thing is to expose the capsule very 
thoroughly, and this I do by means of two free longitudinal 
incisions, one on each side of the patella at a little distance 
from it, and I think it best in the first instance not to open 
the joint. Having made out the limits of the capsule, the tissues 
in front of the synovial membrane are carefully dissected off, and 
the whole of the membrane behind the quadriceps is thoroughly 
exposed. The dissection is then carried on each side well over the 
condyles, remembering that a fold of synovial membrane extends 
backwards for a considerable distance over the surfaces of the 
condyles ; the lateral ligaments are then divided, and the 
synovial membrane separated from them. The dissection is 
then continued inwards to the edge of the patella on each side, 
and behind the ligamentum patella;. The synovial membrane, 
being thus exposed as far as possible by these incisions, is 
then detached all round where it is reflected on to the bone and 
cartilage, and cut away as far back on each side as possible. 
The joint is thus freely exposed from the front, and a fringe of 
synovial membrane is seen around the edge of the cartilages of 
the femur, tibia, and patella ; this is carefully removed, and 
then one may or may not connect the longitudinal incisions by 
a transverse one over the patella, sawing that bone transversely. 
Usually I have not required to make a transverse incision, 
but by dislocating the patella first to one side and then to the 
other, I have been able to get free access to the whole joint. 
The crucial ligaments are next divided and thoroughly cleaned, 
or, if much diseased, removed, and special attention is directed 
to the condition of matters in the intercondyloid notch. The 
joint being then forcibly bent the semilunar cartilages are re- 
moved, and the dissection of the synovial membrane is resumed. 
It is quite easy, as a rule, to define the outer surface of the 
synovial membrane on each side, and having done so separation 
is gradually effected by the finger and some blunt instrument 
between the posterior part of the capsule and the vessels and 
structures behind, and this is continued till the points of reflec- 



COMPLETE ARTHRECTOMY. 189 

tion of the posterior capsule on to the femur above and the tibia 
below are well defined. The synovial membrane is then cut off 
at these points, and the fringe around the cartilages carefully 
removed. Having now got away all the diseased synovial mem- 
brane, the ends of the bones are easily protruded through the 
wound, and the cartilages of the various bones carefully examined. 
If any depressions are seen they are carefully cleaned out, and if 
the cartilage is thin or loose anywhere that portion is removed 
along with a thin layer (\ in.) of the bone beneath. Very often 
the cartilages are covered with a thin layer of soft tissue, and 
this must be got away either by scraping the surface with the 
edge of the knife, or by scrubbing it with a nail brush. If the 
cartilage is absent at any part, and the surface of the bone 
carious, a thin layer of the bone at that part must be cut away, 
remembering that the tubercular tissue only extends into the 
bone for about one-eighth of an inch ; this layer can usually be 
removed by the knife. Of course, if at any part the hole in the 
cartilage or the carious patch of bone are found to lead to a 
deposit in the bone, that must be thoroughly cleared out. 
Having satisfied ourselves by fresh inspection that all the disease 
has been removed, the wounds are closed, the crucial ligaments 
if left being stitched, and the patella if divided being wired. A 
drainage tube is seldom necessary, or if it is used should be 
removed in two or three days. I think it is best in most cases 
not to use a tourniquet, for without it it is easier to distinguish 
disease, the pulsation of the popliteal artery can be felt which 
is of importance in dissecting out the synovial membrane 
posteriorly, and the oozing from the wound is less. Subse- 
quently no passive motion should be employed, and as there 
is a very great tendency to flexion in children, a back splint 
should be worn for a long time, sometimes for years. 

In performing excision as it must be done in view of our 
present knowledge, the synovial membrane must be removed 
with as much care and in much the same manner as has been 
described in the case of arthrectomy; but as the ends of the 



190 ARTHRECTOMY, EXCISION AND AMPUTATION 

bones are sawn off, and all the cartilage-covered surfaces freely 
removed, the operation is considerably shorter, and the chance 
of disease being left behind is diminished. I need not go into 
any details as to the operation of excision, but shall proceed to 
discuss the relative value of the two operations and the points 
which determine our choice. 

The first point is as to the relative danger of the two opera- 
tions. As I have already said, the danger of these operations 
is, on the whole, decidedly greater than that of amputation — the 
clanger being shock. There is also the further question as to 
possible risk of dissemination of the disease as the result of the 
operation. As regards the question of shock, the operations 
which I have described are prolonged operations, and there is 
always a good deal of collapse afterwards, but in only one of 
my arthrectomies has this collapse ended fatally. In two cases 
of excision, however, the patients have died of shock. Both of 
these were extensive operations in weakly persons ; in one, an 
excision of the knee-joint, I had strongly advised amputation, 
but the patient would not submit to it, and begged me to 
excise his knee ; the other was a case of hip-joint disease, with 
extensive affection of the acetabulum and pelvis. 

The second point is as to which operation is most successful 
in eradicating the disease. In answer to this question, I should 
say decidedly that recurrence is less likely after excision per- 
formed as above described than after arthrectomy. This is not 
a matter which in any way lends itself to statistical study, 
because the failures in either case are not failures as regards 
the principles of the operations, but failures in carrying out 
these principles. The parts where it is most difficult to get 
rid of the disease in arthrectomy are about the margins of the 
cartilage, on the surface of the cartilage, where small pits 
containing tubercular tissue may readily be overlooked, and 
recesses of the joint, such as the intercondyloid notch in the 
knee, the olecranon fossa, and the neighbourhood of the orbicular 
ligament in the elbow, &c. These are parts which are cut 



ARTHRECTOMY VERSUS EXCISION. 191 

away or thoroughly exposed in excision, while the diseased 
synovial membrane can be readily removed in either operation. 
Further, in arthrectomy, deposits in the bone are undoubtedly 
more likely to be overlooked than in excision, though in the 
latter operation, also, they are occasionally missed. My own 
experience is that, the greater the care with which the disease 
is removed, the better the residts, and that where arthrectomy 
is thoroughly performed, it is a most satisfactory operation. I 
certainly had more recurrences among the first cases in which 
I performed arthrectomy than I have now when I take greater 
pains to remove, as far as possible, every vestige of the disease. 
The third point to be considered is as to the subsequent 
utility of the limb after these operations, and first as regards 
mobility. As regards arthrectomy, where the cartilages are 
intact, bony anchylosis does not, of course, occur, but if the 
joint is kept long at rest afterwards, there will be much stiff- 
ness, sometimes complete; in most cases, however, there is a 
certain degree of movement, which increases on exercise. As 
a matter of fact, it is not necessary to keep the joint at rest 
for more than a few weeks in order to allow the ligaments to 
reunite, unless in the case of the knee-joint in young children, 
where the tendency to flexion is so great that a posterior splint 
must be continued for a very long time. In the case of ex- 
cision, the subsequent mobility depends in most cases on the 
amount of passive motion employed, though in the case of the 
hip-joint an undesirable degree of mobility sometimes remains 
after excision. In the case of the knee-joint, excision, of course, 
leads to firm stiff joints, and arthrectomy in children usually 
also leads to stiff joints, though somewhat yielding. In some 
cases, however, useful movable knee-joints have been obtained 
after arthrectomy, although I do not think it is a thing to be 
aimed at in children, on account of the risk of flexion. In the 
case of the ankle, a very excellent result as regards movement 
is obtained by arthrectomy combined with removal of the 
astragalus, while after excision a stiff ankle is the common 



192 ARTHRECTOMY, EXCISION AND AMPUTATION. 

result. In the elbow both operations yield a movable joint; 
excision probably gives the greater movement, but arthrectomy 
gives the stronger arm. 

Next, as regards subsequent deformity. This question has 
mainly reference to the knee-joint, where, after both operations 
in young children, there is a marked tendency to flexion, and 
sometimes to rotation outwards and genu valgum. This is a 
matter which will be again referred to, but I may say here 
that, on the whole, the tendency to deformity is somewhat 
greater after arthrectomy than after excision. 

Lastly, as regards subsequent shortening. This is a question 
of immense importance in the case of children, and can be 
answered decidedly in favour of arthrectomy. In that case, 
unless a deposit involves the epiphysial line, there is no inter- 
ference with the growing part of the bone at the operation, and 
consequently no subsequent shortening. In excision, on the 
other hand, the results as regards shortening are very bad, and 
hence, in children, excision of the knee-joint is almost absol- 
utely contra-indicated, and this also holds good as regards other 
joints, though no doubt to a less extent. Even after excision 
of the hip-joint very serious shortening may occur ; I have 
seen one case where it reached eleven inches. It has been 
stated as regards the knee-joint that, if intra-epiphysial excision 
is performed, the interference with growth is not great; but 
the general experience in those cases where bone is sawn off, 
but the epiphysial lines are not touched, is that ossification of 
the epiphysial line is very apt to occur with complete arrest of 
growth. Various other factors probably increase this tendency 
after excision, but they need not be discussed here. 

The conclusion as regards arthrectomy and excision which 
seems warranted by all the facts is that arthrectomy is the 
proper radical operation in children up to fifteen or sixteen 
years of age, and excision in patients who have reached their 
full growth. Certain exceptions as regards arthrectomy in 
adults may be made depending on the individual joints. 



SECTION II. 

SYMPTOMS AND TKEATMENT OF TUBEKCULAK 
DISEASE OF THE VAEIOUS JOINTS AND BONES. 



13 



CHAPTER XVI. 

DISEASE OE THE HIP JOINT. 

Tubercular disease of the hip joint is essentially a disease of 
early life, seldom commencing after the period of puberty. 
Thus, in a chart which I made to illustrate the period of onset 
of disease in various joints and bones, I found, as regards hip- 
joint disease, that 59 per cent, of the total number of cases 
commenced during the first decade of life, 32 per cent, during 
the second, 5 per cent, during the third, none during the fourth, 
2'5 per cent, during the fifth, and 1*5 per cent, afterwards. 
In fact, in the case of the bones and joints in childhood, it is, 
next to the spine, the part which is most frequently the seat of 
tubercular disease, and taking adults and children together, 
disease of the hip joint occupies the third place in the total 
order of frequency. 

As in the other joints, the disease may commence either in 
the bone or in the synovial membrane, but it is by no means 
easy to make out the relative frequency of each in the hip, 
because the joint is deeply placed, and probably a considerably 
larger proportion of the cases of hip-joint disease recover with 
expectant treatment than is the case with any other joint. In 
my own cases also, the rarity of excision has prevented the 
accurate determination of these points. Konig found in museum 
specimens that in 15 cases the disease was primarily osseous 
in 8, and primarily synovial in 7. Haberern found in 132 out 
of 160 cases of excision, that 80 were certainly primarily 
osseous, 23 certainly primarily synovial, and 29 doubtful. 
Blasius, on the other hand, states that primary synovial 
disease is more frequent than primary osseous disease, and, 
as regards the femur, he gives the proportion of osseous and 



196 DISEASE OF THE HIP JOINT. 

synovial disease as 1 to 3. From my own observations, I 
believe that the disease begins somewhat more frequently in 
the bone than in the synovial membrane, but I cannot accept 
results obtained from excision, such as Haberern's, as satis- 
factory, because the cases in which primary osseous lesions are 
present are much more likely to come to excision than those 
where the synovial membrane alone is affected. 

As regards the seat of the primary osseous deposits, many 
authors assert that it is more frequently acetabular than 
femoral. According to Haberern, in his list of 80 cases of 
primary bone disease, 50 commenced in the acetabulum, 23 in 
the femur, and 7 in both. It so happens that in the cases 
which I have excised the majority of the deposits have been 
in the femur, and I think Haberern's proportion of acetabular 
disease is much too high. In the femur the usual seat of the 
deposit is at the lower part of the neck, just outside the 
epiphysial cartilage. In some cases, it is further out in the 
neck and even in the trochanter, but it is seldom that the 
primary deposits are found in the epiphysis. In the acetabu- 
lum the disease generally commences in the neighbourhood of 
the Y-shaped cartilage, and, in some cases, this cartilage may 
be completely destroyed and the pubis may be movable, giving 
a sensation of crepitus. 

The relative frequency of soft caseous deposits and of 
sequestra varies much according to the age of the patient, 
but apparently, in any case, sequestra are most common. 
Thus, to refer again to Haberern's work, we find that of the 
50 cases where the primary seat was in the acetabulum, 31 
were associated with sequestra and 19 were not, while in the 
case of the femur, sequestra were present in 14 and absent 
in 9, and of those where both bones were primarily affected, 
sequestra were found in 6 and absent in 1 ; the total result 
was 51 with sequestra and 29 without. 

The course of events is as follows : — When the primary 
deposit is situated in the calcar, it spreads on the one hand 



PATHOLOGY OF HIP JOINT DISEASE. 



197 



towards the surface and on the other hand towards the epi- 
physial line (see Fig. 31). When it reaches the cavity of the joint 
the synovial membrane becomes affected, and the disease rapidly 
spreads over its whole surface. The soft tissue then extends 
over the articular cartilages of the femur and acetabulum, 
destroying them in the manner formerly described, and, 



§ 




. - 







Fig. 31. — Soft deposit in the neck of the femur, just outside the 
lower part of the epiphysial cartilage. It is destroying this 
cartilage, which is, at one part, completely perforated. It has also 
spread into the joint, and set up synovial disease. The rest of the 
neck is in a state of rarefying osteitis. 

reaching the surface of the bone, produces the condition of 
caries. The affection of the cartilages begins not only from 
the sides but also from the points of attachment of the 
ligamentum teres, which is affected early. As regards the 
cartilage, it must, however, also be noted that it is often 



198 DISEASE OF THE HIP JOINT. 

much thinned at the points where there has heen greatest 
pressure, and there it may be due to osteitis beneath, and not 
necessarily tubercular in the first instance. In the case of 
a primary deposit in the calcar, the disease of the bone not 
only extends outwards into the joint, but also towards the 
epiphysial cartilage, which gradually becomes destroyed, at 
first at one part and subsequently, it may be, throughout its 
whole length ; in the latter case, the head or its remains is not 
unfrequently detached from the femur, and becomes connected 
with the acetabulum by adhesions. 

In some cases, the deposit is situated further outwards 
towards the trochanter, and may not open into the joint at 
all but outside the capsule, and thus lead to the formation of 
abscess not communicating with the joint. In these cases, 
however, the synovial membrane is very apt to become 
involved. 

The disappearance of the head and neck of the femur and of 
portions of the acetabulum in these diseases is due partly to 
the carious destruction of the bones, but chiefly to the rarefying 
osteitis which accompanies it, and this absorption of bone may 
go on rapidly and lead to shortening and bending of the neck of 
the femur and to enlargement of the acetabular cavity. This ab- 
sorption is to a great extent brought about by pressure on the 
parts softened by the inflammation. Pressure of the inflamed and 
carious parts on each other is a very potent factor in keeping 
up rarefying osteitis and in causing the absorption of bone. 
The pressure is not necessarily from standing, for even in bed 
the tonic contraction of the muscles, the result of the irritation 
of the joint, keeps the upper part of the head of the femur 
constantly in contact with and exercising pressure on the upper 
and back part of the acetabulum. The result as regards the 
parts of the bones immediately in contact is twofold ; on the 
one hand, the head of the bone gradually disappears, assuming 
a peculiar flattened shape ; and on the other hand, the aceta- 
bulum becomes absorbed at its upper and back part, new bone, 



DISLOCATION. 199 

though often only to a slight extent, being constantly formed 
from the periosteum around and thus maintaining a buttress (see 
Fig. 32). This enlargement or " wandering " of the acetabulum, 
as it is termed in Germany, often goes on to a very great 
extent, and great shortening and apparent dislocation may 
result from these two processes. In fact, this is by far the 
commonest cause of shortening in hip disease. 

True dislocation is rare, and usually occurs as the result of 
some sudden movement which causes the shortened head and 
neck of the bone to slip out of the enlarged acetabulum, but it 
may sometimes occur even where the articular surfaces have not 




Fig. 32. — Enlargement of the upper and back part of the 
acetabulum ("wandering of the acetabulum"), as the result of 
hip-joint disease. (After Bradford and Lovett.) 

been much affected. Under such circumstances, however, there 
is usually very marked synovial disease with softening of the 
fibrous capsule, and the ligamentum teres has also become 
softened and converted into a tubercular mass. Dislocation in 
hip-joint disease almost always occurs upwards and backwards. 
Cases have, however, been published where the head of the 
bone has passed in other directions, and I have seen two where 
it was dislocated forwards on to the pubis. Partial dislocation 
is more common and is due to destruction of the margin of the 
acetabulum without the formation of an efficient buttress. In 
this case the centre of the head may be caught on the edge of 
the acetabulum and a groove formed in it at the point of 
pressure. 



200 DISEASE OF THE HIP JOINT. 

While the enlargement of the acetabulum and the absorption 
of the head of the femur are going on caseation of the tubercular 
tissue is taking place, and thus the joint cavity generally 
contains a quantity of caseous material. About this time also 
chronic abscesses form around the joint, either outside or inside 
the pelvis. Those outside the pelvis usually communicate 
with the joint, though often by a very small opening, some- 
times difficult to find. Their most usual seats are on the 
anterior and outer surface of the joint or behind in the gluteal 
region. 

In considering the symptoms and treatment of hip-joint 
disease it is convenient to speak arbitrarily of several stages 
but it is not always easy to say of any given case in which 
stage it is because the various stages run into one another. I 
shall describe four stages as follows : — 1. Where the cartilages 
are still, in the main, intact, the acetabulum not enlarged, and 
the neck of the femur not absorbed. Here there is no shorten- 
ing. 2. Where shortening is occurring, the acetabulum 
becoming enlarged, the cartilages being destroyed and other 
destructive changes taking place, but where as yet there is 
no abscess. 3. Where in addition to these changes, which, 
however, may not have gone on to any great extent, we have 
the occurrence of chronic suppuration either inside the joint or 
outside as well as in the form of chronic abscesses. This stage 
also includes cases where the abscesses have burst or been 
opened, and where sinuses remain. 4. The stage of recovery 
with deformity. 

1. Symptoms of the Fiest Stage. 

Hip-joint disease most usually begins insidiously, though in 
some cases the onset is more or less acute. Even where an 
injury has apparently been the exciting cause of the disease, 
some weeks may elapse before any sufficiently definite symp- 
tom of the disease is noted. Usually when it is noticed that 



SYMPTOMS OF THE FIRST STAGE. 201 

there is something wrong with the hip, the friends of the 
patient can call to mind that there has been a feeling of tired- 
ness, or even pain, in the limb; that there has been a little 
limping, especially in the morning, and a tendency to bear more 
weight on the toes than on the heel, and to keep the knee 
slightly flexed; that the patient has been pale, the appetite 
capricious, and the sleep disturbed. 

As a rule, at the earliest period (probably after disease has 
existed a few weeks) at which the patients are brought to 
consult a surgeon, the symptoms are quite mild, and sometimes 
difficult to recognise. There is a slight limp, or rather dragging 
of the leg, especially in the morning; the knee is somewhat 
flexed, the patient does not put the heel to the ground in 
walking, but bears weight on the ball of the toes, he is not so 
active as formerly, but does not in most cases complain of much 
pain and then generally on the inside or front of the knee, 
and there is some obliquity of the pelvis towards the affected 
side, leading to apparent lengthening of the limb. On looking 
at the limb the hip and knee are seen to be slightly flexed, 
there is slight apparent lengthening, the thigh is abducted and 
somewhat rotated outwards, and the movements of the limb are 
restricted (see Fig. 33). Viewed from behind, the buttock on 
the affected side is seen to be somewhat flattened, mainly due 
to the position of the limb, but sometimes, even at this early 
stage, due in part to commencing atrophy of the muscles (see 
Fig. 34), which is such a constant and early accompaniment 
of all synovial inflammations. The muscles of the thigh also 
waste at an early period, and both in the buttock and the 
thigh the muscular contractility is much diminished. At 
this stage, unless in the acute cases, or where the disease is 
situated in the neck of the bone, there may not be any marked 
thickening of the tissues around the joint, but this varies very 
much, for even in these insidious cases, especially where the 
disease has been purely synovial at the commencement, the 
synovial membrane may be considerably thickened before there 



202 



DISEASE OF THE HIP JOINT. 



are any pronounced symptoms, and thus the fold of the groin 
may be more filled up than on the other side. 

In examining the condition of the joint, the patient should 
be laid on his back on a flat table, and when the lumbar spine 
lies flat on the table, it will be seen that the thigh is bent to a 
varying degree, while, when the thigh is placed flat on the 





Fig. 33. — Hip-joint disease on 
the right side, obliquity of the 
pelvis towards the affected side, 
and slight flexion of thigh. 



Fig. 34. — Same case (as Fig. 
33), seen from behind, showing the 
flattening of the buttock and the 
obliquity of the pelvis. 



table, the lumbar spine becomes arched forwards (see Pigs. 35 
and 36). As, however, in quite early cases this sign may be 
absent, while, on the other hand, it occurs in other affections, 
such as psoas abscess, the best plan is to follow it up by the 
converse procedure, viz., the study of the degree of flexion. 
This method is of especial value in infants and young children. 



SYMPTOMS OF THE FIRST STAGE. 



203 



For this purpose the child is again placed on his back, with the 
lumbar spine flat on the table. What is supposed to be the 
sound leg is first taken, flexed completely on the abdomen, and 
held in that position. The other thigh is then flexed gently 
and slowly, and it will be found that when, or before, a right 




Fig. 35. — Hip- joint disease, showing the degree of flexion of the 
thigh when the spine is lying flat on the table. 

angle is reached the flexion ceases, and on attempting to 
push it further, the pelvis rises from the table. This sign is 
also found sometimes in sciatica, but in the case of hip-joint 
disease, when the limb is kept at the limit of flexion, attempts 
at abduction, adduction, or rotation almost at once involve 




Pig. 36. — Hip-joint disease, showing the arching of the spine when 
the flexed thigh is pulled down (see Fig. 35). 

movement of the pelvis ; if that is the case, the diagnosis of 
disease of the hip-joint may be safely made. A further point 
in the diagnosis is the actions which cause pain. This is quite 
a secondary matter, and for my own part I avoid any such 



204 DISEASE OF THE HIP JOINT. 

investigation as a rule, for it only frightens and hurts the 
patient without throwing any additional light on the nature of 
the case ; the restriction of the movements, which have been 
described, are of themselves quite sufficient. At this early 
stage movements of flexion, rotation (especially inwards), and 
adduction, if carried to excess, cause pain ; but the pain from 
jarring the limb by a blow on the knee or trochanter varies 
much in different cases, and is, as a rule, slight. The restric- 
tion of the movement, to which I have referred, is in the early 
stage almost entirely due to muscular contraction, and is very 
much diminished when the patient is examined under chloroform, 
nor is there any grating to be felt in the joint. 

The diagnosis of tubercular disease is sometimes very difficult 
at this stage. Apart from the characteristic signs of disease 
of the hip-joint, the insidious onset of the disease, and, where 
it is attributed to an injury, the quiescent interval which 
usually intervenes before the symptoms commence, are sufficient 
to excite very grave suspicions. These are much strengthened 
if tubercular lesions are found elsewhere, and the suspicion 
becomes almost a certainty, at any rate in young subjects, if 
the symptoms do not yield to treatment in the course of a few 
weeks. The most difficult matter is to distinguish tubercular 
disease from subacute synovitis, due to some temporary cause, 
such as an injury. In that case the symptoms are always 
more acute and rapid in their onset, and when due to injury, 
follow almost immediately on it. The matter is very readily 
settled, however, by watching the effect of treatment. Where 
I suspect simple synovitis, I always put the patient to bed, 
without any apparatus, and tell the parents to prevent the 
child from getting up and standing for a week or ten days. 
At the end of that time, if the affection is a simple synovitis, 
distinct improvement will usually be noted, even without the 
use of retentive apparatus, whereas, if the disease is tubercular, 
the patient will probably be worse, or at any rate not markedly 
better. 



DIAGNOSIS OF THE FIRST STAGE. 205 

Another difficulty in diagnosis is from the congestive condi- 
tion of the bones during rapid growth, " growing pains " as it is 
popularly called, or the " Fievre de croissance " of the French. 
This condition is usually met with near the age of puberty 
(15-17 years of age), affects the bones rather than the joints, 
more especially the lower part of the femur and the tibia, and 
is not limited as a rule to one joint or bone. It may be accom- 
panied by fever and subsides very rapidly on rest in bed. 

In older patients commencing monarticular rheumatism and 
rheumatoid arthritis must also be borne in mind. As a matter 
of fact, in old patients tubercular hip-joint disease is much less 
common than either of the other affections mentioned, and, there- 
fore, the presumption is against it, and in the early stage in 
old people it is almost impossible to diagnose tuberculosis. 
In favour of it would be the greater pain and fixity of the 
joint, absence of grating, and the presence of other tubercular 
lesions : at a later stage the formation of a chronic abscess 
would definitely settle the diagnosis in favour of tuberculosis, as 
also would distinct evidence of enlargement of the acetabulum. 
In the case of rheumatoid arthritis grating is observed early, 
and thickening from outgrowths from the bones are present. 

The diagnosis must also be made from other diseases not 
affecting the hip-joint, and of these perhaps the one most 
commonly confounded with it is spinal disease with psoas 
abscess, especially where there is no spinal curvature. Here 
the mistake arises from placing too much reliance on the 
difficulty of complete extension in hip-joint disease, and the 
consequent arching of the back, for in psoas abscess the leg is 
also frequently flexed and cannot be properly extended. In 
psoas abscess, however, there is no difficulty in flexion unless 
the abscess is large and has passed into the thigh, in which case 
there may be a mechanical obstruction to complete flexion, but 
in psoas abscess with the limb at right angles or at the position 
of greatest possible flexion there is no movement of the pelvis 
nor any restriction when the leg is abducted or rotated out- 



206 DISEASE OF THE HIP JOINT. 

wards and only in some cases when adducted, while there is a 
difficulty in rotating inwards. Further, in the case of psoas 
abscess fulness and fluctuation can generally be detected deep 
down in the iliac fossa and higher up in front of the loin, the 
latter point differentiating it from abscess in the iliac fossa in 
connection with hip-joint disease, which does not ascend above 
the level of the iliac fossa. Then lastly, in spinal disease, even 
where no curvature is present, the lumbar curve (if the lumbar 
region is the seat of disease) is usually diminished or absent, 
and wherever the disease is present that part of the spine is 
rigid, and pain can generally be elicited by firm pressure on 
the transverse processes of the vertebrae. 

In the more acute forms of hip-joint disease the question of 
diagnosis arises from acute osteomyelitis in the upper end of 
the femur, and from the gummatous epiphysitis of infants. 
The former affection is distinguished by the presence of fever 
which very rarely occurs to any great degree in tubercular hip- 
joint disease, by marked tenderness at the upper part of the 
femur, by thickening of the bone, and by the early and rapid 
formation of abscess. The latter condition is rare at the upper 
part of the femur, but if present is characterised by swelling, 
tenderness, powerlessness of the limb, and other signs of con- 
genital syphilis. 

It is usual in giving the differential diagnosis of tubercular 
hip-joint disease to mention spinal disease without abscess 
and sacro-iliac disease, but as I shall refer to this point again 
I need only say here that with anything like a careful 
examination no confusion need arise. I have also seen infantile 
paralysis and appendicitis mistaken for hip-joint disease, but 
the free mobility and the loss of power in the limb in the 
former case, and the fever, seat of tenderness and swelling, and 
the free mobility of the hip when the abdominal muscles are 
relaxed in the latter are sufficient to exclude the diagnosis of 
hip-joint disease. Again, I have seen a tumour of the pelvis, 
and also a tumour of the upper part of the thigh, mistaken for 



SYMPTOMS OF THE FIRST STAGE. 207 

hip-joint disease on account of the restriction of the movements, 
the pain and the swelling. Lastly, sciatica and hysteria have 
also to be borne in mind. In sciatica the pain extends down 
the back of the thigh and leg, and there are tender points along 
the course of the sciatic nerve : there is no pain on extension 
or movement in a semiflexed position, but complete flexion is 
usually impossible on account of the pain due to stretching of 
the sciatic nerve, and the flexion is still more restricted if at 
the same time the leg is kept extended at the knee-joint. The 
hysterical affection is more difficult to diagnose in the hip than 
in most of the other joints, on account of its deep seated posi- 
tion, but it is also much rarer than the others. Here one must 
be guided by the presence of other signs of hysteria, the irregu- 
larity of the symptoms, the absence of shortening, even although 
the disease has lasted for some time, and the freedom of move- 
ment under chloroform. 

The symptoms which I have described are those which 
commonly occur in the early stage of hip-joint disease, especi- 
ally where the disease has commenced primarily in the synovial 
membrane, or where the bone deposit has not yet communi- 
cated freely with the joint, but in some cases the symptoms 
begin more acutely and the position assumed by the limb is 
different. The chief variations are the following : — The pain 
may be very great from or soon after the commencement of 
the disease, and be chiefly complained of on the inner side and 
front of the knee. It may be excited by very slight movement, 
even by jarring of the bed, being due in that case to spasm of 
the muscles set up by the jar driving the inflamed bony sur- 
faces together. This great tenderness of the joint is always 
accompanied by starting of the limb at night. The starting 
occurs generally as the patient is dropping off to sleep or as he 
wakes up, and is due to sudden and irregular spasm of the 
muscles when the control of the will is lost. It also occurs 
during sleep, waking up the patient, and is probably often set 
up by turning in sleep. In bad cases this starting occurs many 



208 DISEASE OF THE HIP JOINT. 

times during the night and leaves much aching behind. The 
child thus frequently cries out at night, and suffers much from 
want of sleep. The tenderness of the joint is further evidenced 
by the way in which the patient supports and lifts the leg by 
means of the other foot. In these cases the position assumed 
from the first is often adduction, and flexion with tilting 
upwards of the pelvis on the affected side giving rise to ap- 
parent shortening. In other cases there is marked thickening 
about the joint, either in front corresponding to the synovial 
membrane, or affecting the neck of the femur or the inner 
surface of the acetabulum. 

These variations depend on the pathological condition, and to 
some extent indicate the state of matters in the interior of the 
joint. The insidious onset which I have described in the first 
instance coincides either with primary synovial disease, or with 
some osseous deposit which has not yet opened freely into the 
joint, although it may have affected the synovial membrane. 
Where the disease commences acutely, or where, after going on 
slowly for a time, it suddenly becomes acute, the primary seat 
of disease has been the bone, and the acute onset corresponds 
with the escape of tubercular material from the osseous deposits 
into the cavity of the joint, leading to rapid infection of all the 
structures of the joint. Severe starting pain implies inflam- 
mation of the bone, rarefying osteitis, especially beneath the 
cartilage, and indicates early destruction of the cartilage, 
absorption of the neck, and enlargement of the acetabulum. 

In a certain number of cases, it is possible at an early 
period to diagnose the primary seat of the lesion before 
all the structures of the joint have become affected, and 
where this can be done the knowledge may have a very 
important bearing on treatment. The points to be examined 
are the relative size of the trochanters and the neck of the 
femora, the relative fulness in the groins, the condition of the 
inner surfaces of the acetabula as felt from the rectum, and 
the degree of restriction of movement. Where the disease has 



SYMPTOMS OF THE FIRST STAGE. 209 

commenced in the synovial membrane, and is still confined to it, 
there is fulness in the groin on that side, and measurement by 
callipers applied over the femoral artery in front, and at a 
corresponding place behind, shows a difference of a quarter to 
half an inch between the two sides. Further, there is no 
thickening about the trochanter or on the inner surface of the 
acetabulum, and the movement is not in the first instance greatly 
restricted. Where the disease has commenced in the neck of 
the femur, it may be that when we first see the patient, the 
deposit is limited to the substance of the bone, and has not yet 
communicated with the joint, or it may have infected the 
synovial membrane, or have opened freely into the joint. In the 
first case, there is thickening about the trochanter and neck of the 
femur without thickening of the synovial membrane, and when 
the deposit is in its usual position, viz., outside the epiphysial 
line, only slight pain and restriction of movement. In the 
second case there is in addition to the symptoms just mentioned 
fulness in the groin due to thickening of the synovial membrane, 
and somewhat greater restriction of movement ; no thickening 
to be felt per rectum. In the third instance, the symptoms 
become acute when the deposit opens into the joint, and the 
symptoms are thickening about the trochanter, fulness in the 
groin due rather to fluid in the joint than to synovial thickening 
and glandular enlargement, much pain and starting, and marked 
rigidity of the joint from muscular contraction ; no thickening 
inside the acetabulum. Where the disease commences in the 
acetabulum, the whole substance of the bono is usually affected, 
so that, on the one hand, the whole surface of the joint is early 
attacked, and, on the other hand, the periosteum on the pelvic 
side is thickened, and often there is a collection of cheesy matter 
or of pus between the periosteum and bone. Hence, the local 
signs are much pain and rigidity at an early period, some fulness 
in the groin, thickening on the pelvic surface of the acetabulum 
as felt by the finger in the rectum, no thickening of the 
trochanter or neck of the femur. Erichsen also states that in 
14 



210 DISEASE OF THE HIP JOINT. 

acetabular disease the pain is more in the region of the hip- 
joint than about the inner side of the thigh and knee as is 
usually the case. 

2. Symptoms of the Second Stage. 

In this stage the articular cartilages disappear more or less 
completely, the acetabulum enlarges in the upward and back- 
ward direction, and the neck of the femur becomes altered in 
direction and absorbed. In a good many of these cases, the 
process is accompanied by the formation of pus, but it is best in 
practice to exclude from the second stage all those cases in 
which there are visible abscesses or sinuses. 

As this stage comes on, the position of the limb generally 
alters, and instead of abduction and apparent lengthening, the 
limb becomes adducted, and in some cases rotated inwards, while 
the flexion increases, and the pelvis on the affected side becomes 
higher than on the other. 

In addition, there is a greater or less degree of real shorten- 
ing, and from the tilting of the pelvis, the shortening becomes 
apparently greater than it really is. There is also increased 
pain and rigidity at the hip-joint, increased atrophy of the 
muscles, shortening of the neck of the femur, and it may be 
real dislocation. The methods of examination as regards move- 
ment are the same as have been previously described, but as 
additional investigations must be made, it will be well to refer 
to some of the individual points in detail. 

Where no treatment has been adopted during the first stage, 
the flexion is usually considerable, and may be a good deal 
more than half a right angle. This flexion is partly due to the 
greater ease of the position, and partly to the greater strength 
of the flexors over the extensors. The amount of flexion is con- 
siderably masked when the patient is standing, especially when 
he places his toes on the ground, owing to the lordosis of the 
lumbar spine, which is, of course, excessive when the flexion is 



SYMPTOMS OF THE SECOND STAGE. 



211 



great (see Figs. 37 and 38). In estimating the degree of flexion, 
therefore, it is necessary, just as in the first stage, that the 
patient he laid on his back on a flat table. The lumbar spine is 
then pressed down till it is lying flat on the table, or the limb 
pushed up till the same thing happens, and the point made out 
when, on further extension of the thigh, the spine begins to arch. 








Fig. 37. — Hip -joint disease, 
showing the degree of flexion. 
(After Bradford and Lovett.) 



Fig. 38. — Hip-joint disease (see 
Fig. 37), showing extreme lordosis, 
when an attempt is made to bring 
the foot to the ground. (After 
Bradford and Lovett.) 



The angle which the thigh forms with the table can then be 
readily measured. 

The adduction of the limb is the most troublesome deformity 
from the point of view of treatment. The adduction is very 
evident on inspection, not only from the inclination of the 
affected limb towards the sound one, but also from the deep 
groove at the junction of the thigh and the perineum. The 



212 DISEASE OF THE HIP JOINT. 

adductors, more especially the adductor longus, are shortened 
and may require division before the limb can be got straight. 
The degree of adduction can be measured by the goniometer, 
the transverse bar being laid across the two anterior iliac spines, 
and the indicator placed parallel with the thigh on the affected 
side. 

The greater the adduction the greater the obliquity of the 
pelvis, and the greater the difference between the apparent 
and the real shortening. Based on this fact, Lovett has con- 
structed a table by which the amount of adduction can be 
readily determined by ascertaining, on the one hand, the 
distance between the anterior superior spines, and on the other, 
the difference between the real and the apparent shortening. 
I copy this table from Bradford and Lovett's book. Eeal 
shortening is ascertained in the ordinary way by measuring the 
distance between the anterior superior spine and the internal 
malleolus on each side, and Lovett takes the apparent shortening 
by measuring the distance between the umbilicus and the 
internal malleolus of each side. The difference between the 
real shortening and the apparent shortening is then taken, and 
the balance remains as the shortening due to tilting of the 
pelvis. " Take an example : — Length (from anterior superior 
spine) of right leg, 23 inches ; of left leg, 22£ inches. Length 
(from umbilicus) of right leg, 25 inches ; of left leg, 23 inches. 
Eeal shortening, \ inch ; apparent shortening, 2 inches. Differ- 
ence between real and practical shortening, 1\ inches. Distance 
between anterior superior spines (pelvic measurement), 7 inches. 
If we follow the line for 1\ inches, until it intersects the line 
for pelvic breadth of 7 inches, we find 12° to be the angular 
deformity, and as the practical shortening is greater than the 
real, it is 12° of adduction of the left leg." 

Botation inwards not unfrequently takes the place of 
rotation outwards during this period, but unless true dis- 
location on to the dorsum has occurred, it is not excessive. 

During the progress of this stage the limb becomes shortened 



SHORTENING. 



213 



from |~inch to 2 or 2\ inches ; the average is l-J inches when 
the disease conies to a standstill. After the active disease has 
passed off,f urther shortening may also take place. The shortening 
during the active stage is, as I have already mentioned, usually 





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Difference in inches between real and apparent shortening. 

due to absorption of the head and neck of the femur and altera- 
tion in the angle of the neck and shaft, further to absorption of 
the upper and back part of the acetabulum, leading to enlarge- 
ment of the acetabulum in that direction, and slipping up of the 



214 DISEASE OF THE HIP JOINT. 

head of the femur, in some cases to true partial or complete 
dislocation, and in some rare instances to perforation of the 
acetabulum and passing of the shortened head and neck into the 
opening. After the disease has come to a standstill the further 
shortening is due to deficiency in growth of the limb. To 
ascertain the actual shortening, measurements are first made 
from the anterior superior spine of the ilium to the internal 
malleolus. The lowest point of the anterior superior spine, 
where it turns backwards, is marked on the skin on both sides 
and also the tips of both internal malleoli. The leg is then 
extended at the knee-joint and the distance between the points 
measured off. In doing this the hands should not rest on the 
skin, lest the marks be displaced, and it should be noted that 
the tape does not touch anywhere, and that it is in a plane 
parallel to the leg. Further, the sound limb must be placed in 
exactly the same position as the diseased one as regards flexion, 
adduction, and rotation, otherwise error will arise. The difference 
between these two measurements gives the amount of real 
shortening of the limb, but this may be due not only to alteration 
about the hip-joint itself as the result of the disease, but also to 
deficient growth of the limb if the disease has lasted for some 
time. The amount of shortening due to changes at the hip- 
joint itself is ascertained fairly well by observing how far the 
tip of the trochanter is above Nekton's line. Draw a line from 
the lowest point of the anterior superior spine of the ilium to the 
most prominent point on the lower and posterior surface of the 
tuber ischii. Normally this line will touch the tip of the 
trochanter. The distance which the tip of the trochanter is 
above this line indicates the amount of shortening due to 
changes at the hip-joint, and the difference between this measure- 
ment and the total real shortening ascertained as above described 
indicates the deficiency in the growth of the limb. 

Another measurement which is of importance as indicating 
the degree to which the changes about the hip have proceeded 
is that of the relative distance of the two trochanters from the 



CHANGES IN THE NECK. 215 

middle line. This measurement is readily made by means of a 
bar with an indicator fixed at its centre, and from this towards 
each side the surface is marked off in inches and parts of an 
inch ; sliding on each end of this bar is a vertical arm. The bar 
is laid on the abdomen at the level of the trochanters, exactly 
at right angles to the axis oE the body, and with the indicator in 
the middle line, the lateral arms are then slipped inwards till 
they touch the outer surface of the trochanters, and the 
measurement on each side is then read off. Where one 
trochanter is decidedly higher than the other, then the bar 
must be placed at the level of the middle of the trochanter on 
the affected side, and on the sound side a line must be continued 
upwards from the outer surface of the trochanter parallel with 
the axis of the body. It will be found that at this stage of 
the disease, unless true dislocation on to the dorsum has 
occurred, the trochanter on the diseased side is nearer the 
middle line than the other. The cause of this is either 
absorption of the head and neck of the femur or deepening of 
the acetabulum, with sinking in of the head, and the diagnosis 
between these may be made by rectal examination, which 
sometimes shows thickening over the inner surface of the 
acetabulum in the latter case and not in the former. The 
chief importance of this measurement is, however, that it 
indicates whether the shortening is due to true dislocation on 
to the dorsum or simply to enlargement of the acetabulum. 
In the former case, unless there has been separation of the 
head or great absorption of the neck, the trochanter will be 
further away from the middle line on the affected side than 
on the sound one, while in the latter, as I have just pointed out, 
the reverse will be the case. 

True dislocation is comparatively rare in hip-joint disease, 
but it does sometimes occur, and then usually about the 
commencement of the second stage. The most common form 
is dislocation on to the dorsum, but its mechanism is quite 
different from that of dislocation occurring as the result of 



216 DISEASE OF THE HIP JOINT. 

injury. Instead of the head of the bone passing out through a 
hole in the lower part of the capsule, the capsule either stretches 
or tears at the upper and back part, and the head then simply 
slips upwards on to the dorsum or sometimes becomes caught 
on the rim of the acetabulum, a deep groove being then formed 
on the head at that part. Preceding- the dislocation, the 
acetabular cavity usually becomes filled up by soft tissue chiefly 
arising from proliferation in connection with the ligamentum 
teres; at the same time the ligaments become softened and 
stretch. Where dislocation on to the dorsum occurs, the position 
characteiistic of the second stage becomes exaggerated, more 
especially the rotation inwards. More rarely the head of the 
bone passes forwards and upwards so as to lie below the anterior 
superior spine of the ilium. In four cases of this kind which I 
have seen, the dislocation occurred suddenly, in two of them 
during sleep. The limb becomes rotated outwards to a marked 
degree, adducted, and flexed. 

The pain in the early period of the second stage increases 
in degree coincidently with the destruction of the articular 
cartilages and the caries of the surface of the bone, the pain 
being both around the hip and also on the front and inner side 
of the thigh and knee. The starting pains at night and the 
pain on movement and jarring the limb also increase. Towards 
the end of the second stage the pain diminishes on account of 
the increased fixation of the joint from partial anchylosis. 

As the cartilages become destroyed, and the surface of the 
bones becomes carious, the rigidity of the joint also increases 
being still, to a" large extent, the result of muscular contraction 
but also, to some extent, due to shortening and thickening of the 
capsule, and towards the end of the stage to fibrous or bony 
anchylosis. The atrophy of the muscles, both of the buttock 
and also of the thigh, progresses rapidly, and, as mentioned with 
reference to the first stage, their reaction to faradism is very 
much diminished. 

As regards the general condition of the patient during this 



DIAGNOSIS OF THE SECOND STAGE. 217 

stage, he becomes thin and pale and his appetite poor and 
capricious ; he is disinclined to move about, and his sleep is 
very much disturbed. 

Apart from the diseases which are apt to be confounded with 
hip-joint disease, and which have been already mentioned, there 
are certain others which have to be borne in mind in examining 
a case in the second stage. 

On hurried examination a congenital dislocation of the hip 
might be looked on as hip-joint disease, especially if only one 
hip-joint is affected. There is shortening of the limb, limping, 
and lordosis in congenital dislocation as in hip-joint disease, 
but in the former, instead of restriction of movement, there is 
excessive freedom of movement, without pain ; by extension, 
the limb can generally be drawn down to its full length, and, 
on the other hand, the head of the bone can be readily pushed 
up again. 

In older people, the diagnosis from rheumatoid arthritis is 
often a very difficult matter on account of the deeply seated 
position of the joint. In both there is limitation of movement, 
and pain on movement, but in rheumatoid arthritis the shorten- 
ing, flexion, and adduction are not such marked features, and 
there is usually considerable thickening about the bone. In 
the early stage, grating is felt in the joint, other joints are often 
affected, and there is absence of other tubercular lesions. 

In old people also it sometimes happens that after a fall on 
the hip-joint pain persists, and the limb becomes somewhat 
shortened, the condition, in some cases, being an osteitis, with 
absorption of the neck of the femur, though in others, no doubt, 
rheumatoid arthritis is set up by the injury. 

Charcot's disease also occasionally affects the hip-joint, but 
there the symptoms are acute in the first instance, with pain 
and swelling about the joint, followed by increased looseness of 
the joint, which may be dislocated without pain, and usually 
accompanied by the early symptoms of locomotor ataxia, 
especially by the Argyll Kobertson pupil. 



218 DISEASE OF THE HIP JOINT. 

It is hardly necessary to refer to the diagnosis from true 
dislocation, in which the displacement occurs suddenly after a 
severe accident, and in which the malposition is at once 
complete and more marked than that in hip-joint disease. 

3. Symptoms of the Third Stage. 

The third stage is somewhat arbitrarily formed to include 
all cases where abscesses have formed, and are either still 
unopened or have burst, leaving sinuses. This division is 
introduced on account of its clinical importance, and not on 
account of its pathological significance, for abscesses may 
occur early or late in hip-joint disease. Perhaps most often 
where abscesses are present they occur about the middle 
of the second stage, though sometimes where the case is 
acute they occur early, before any marked shortening, or, on 
the other hand, at a late period, after the disease seems to have 
come more or less to a standstill. These abscesses may appear 
either inside or outside the, pelvis, most commonly outside. 
Those which occur in the limb usually point either in front of 
the trochanter or in the buttock, and they may or may not 
communicate with the hip-joint. In some cases the abscesses 
begin in the outer part of the capsule, and spreads outwards 
rather than inwards to the joint. In other cases, especially 
where there is a deposit in the bone towards the outer part 
of the neck, the periosteum may be detached from the bone and 
pus may burrow its way under it outwards, escaping beyond 
the attachment of the capsule, and then form an abscess ; 
indeed, cases have been published where this has occurred 
when the deposits in the neck of the femur were in their 
usual situation, and where the abscess was opened, the 
necrosed fragment removed, and the case cured without 
opening the joint. Usually, however, on opening the abscess, 
a small canal will be found leading through the capsule into 
the joint. 



PELVIC ABSCESS. 219 

The pelvic abscesses usually make their way into the iliac 
fossa, and point above Poupart's ligament, but, in some cases, 
they pass downwards into the ischio-rectal fossa or perineum. 
As regards these abscesses in the iliac fossa, Haberern, who 
has written an excellent paper on the subject, describes four 
modes of origin : — 1. The abscess may be associated with 
disease or perforation of the acetabulum. This occurs most 
often in connection with primary disease of the acetabulum, 
the pus, in these cases, forming under the periosteum in 
the first instance. 2. The abscess arises by rupture or 
perforation of the capsule of the joint at its upper and 
inner part, the pus then passing upwards over the innomi- 
nate bone into the iliac fossa. This form is rare. 3. The 
capsule may be perforated at the middle of the ilio-femoral 
ligament, and an abscess develops between the adductors and 
may pass into the pelvis along the ilio-psoas muscle. 4. The 
abscess may not communicate with the joint or with diseased 
bone, but arise from suppuration of the glands in the iliac fossa, 
which are often enlarged in cases of hip -joint disease. 

The key to the diagnosis of the point of origin of these iliac 
abscesses lies mainly in the examination per rectum. If with 
the finger in the rectum swelling is felt on the inner surface of 
the acetabulum the probability is that the abscess has started 
from that point, and if that is the case, on sharply pressing on 
the iliac swelling fluctuation will be felt by the finger in the 
rectum. If there is no swelling to be felt per rectum in the 
true pelvis then it is probable that the abscess has originated 
in one of the other three ways mentioned. (In some cases, 
however, the channel of communication with the iliac fossa 
may be very narrow.) The next point would then be to see 
whether there is any fulness in front of the hip-joint or at the 
inner side, and whether fluctuation can be detected between 
the hand in various positions below Poupart's ligament and the 
hand above Poupart's ligament. If not, then the abscess is 
most likely of glandular origin. As regards the other two 



220 DISEASE OF THE HIP JOINT. 

forms, fluctuation will be felt on the inner side of the joint in 
the neighbourhood of the lesser trochanter in the third form, 
but not in the second. 

Where the abscesses have burst or have not been opened 
aseptically sinuses are found, and usually in neglected cases 
there are several sinuses around the joint, often all leading to the 
same aperture in the capsule and through that to carious bone. 

During the formation of these abscesses the temperature is 
usually somewhat elevated and higher in the evening than the 
morning, but it seldom reaches 100°, ranging usually between 
98'8 and 99-6. "When sinuses have formed the temperature 
may be higher for a time, unless they become quiescent, but 
usually, once a sinus forms, sepsis takes place and the pus bags 
in pockets of the original abscess, the skin becomes red and 
thin over them, and fresh sinuses are formed. During the 
formation of these fresh sinuses the temperature usually goes 
up and falls again when the pus escapes. The general condition 
of the patient during this stage also becomes worse, he loses 
flesh and strength, various internal organs become lardaceous, 
and, in many cases, after months or years of suffering he dies 
of hectic fever and exhaustion. 

4. Symptoms of the Fourth Sta&e. 

A fourth stage may also be described, where the disease 
gradually improves and where a certain amount of anchylosis, 
sometimes completely bony, takes place. This stage may 
follow the previous ones or, while recovery is taking place 
in the main, the disease progresses elsewhere and abscesses 
and sinuses form. Where care has not been taken in the 
early treatment more or less deformity is usually present in 
the form of flexion and adduction. Where anchylosis is 
present a slight degree of these deformities is not of very great 
moment, in fact, very slight flexion enables the patient to sit 
more comfortably than when the limb is quite straight. When 



SYMPTOMS OF THE FOURTH STAGE. 221 



carried to any considerable extent, however, great lameness and 
difficulty in walking is produced. Where flexion is present 
lordosis is developed in order to enable the foot to reach the 
ground, and consequently great lameness and deformity, and 
where adduction is at all marked the pelvis is much tilted and 
the practical shortening greatly increased. The combination of 
the two deformities cripples the patient, 
sometimes entirely, and calls for operative 
treatment. 

In some cases, though rarely, both hip- 
joints become diseased. In that case they 
do not usually become affected simul- 
taneously but after an interval of some 
months, and it is stated that the disease 
in the second joint is not so severe as 
in the first, especially as regards the 
question of pain. This condition, if not 
properly treated, is very apt to give rise 
to a peculiar deformity — " crossed leg 
deformity" — the result of adduction on 
both sides. The feet are quite crossed, 
and the patient has great difficulty in 
standing (see Fig. 39). In some cases, 
however, where the adduction is marked 
and the feet well clear of each other, he 
can progress by a sort of rocking motion. 




Fig. 39. — Cross-legged 
deformity, the result of 
disease of both hip-joints. 
(After Bradford and 
Lovett. ) 



Prognosis of Hip-Joint Disease. 

Hip-joint disease is without doubt a 
grave disease, but a. great deal depends 
on the treatment which is adopted and the care with which 
it is carried out. When the case is placed under proper 
treatment at an early stage of the disease the chances of 
ultimate recovery are very considerable, but a long time 



222 DISEASE OF THE HIP JOINT. 

must elapse (from 3 to 7 years) before the cure can be reckoned 
complete. In some few cases there is perfect recovery of the 
joint, but in most instances there is more or less restriction 
of movement, and where the second stage has been reached 
before proper treatment was adopted the restriction of move- 
ment is usually great. Much depends on whether suppuration 
has taken place or not ; if it has, the outlook is decidedly less 
favourable both as regards the recovery of the joint and of the 
general health. 

Various estimates are given by different authors as to the 
mortality in hip-joint disease, and most put it at about 30 per 
cent. Part of this mortality is, however, due to long continued 
suppuration and septic diseases which are avoided under 
strict aseptic treatment, and in my experience it is distinctly 
too high. The essential cause of death is from tubercular 
disease elsewhere, usually phthisis or tubercular meningitis, 
and, as I mentioned in Chapter VIIL, the mortality from these 
troubles, at any rate within a few years after the commencement 
of the disease, is under 30 per cent. I have already referred 
to statistics which I drew up some years ago, and among 
them there is a record of 77 cases of hip-joint disease which 
had been admitted to the hospital. Of these 77 cases, 14 had 
suffered, or were suffering, from tubercular disease elsewhere 
when admitted. Of these, 6 died, 4 from tubercular meningitis, 
1 from peritonitis, and 1 from exhaustion from long continued 
suppuration (a case admitted with suppurating sinuses). In 
addition 3 cases were suffering from phthisis. Of the 77 cases, 
24 were discharged as cured, and 23 as much improved, or 
61 per cent, cured or improved. In 15 the final result is not 
definitely stated, but the last notes mention steady improve- 
ment : in 7 the notes are incomplete. The mortality was 6, or 
almost 8 per cent., but if we also reckon that the cases 
suffering from phthisis died, we have a mortality of nearly 12 
per cent., and probably, also, some of the 7 which are incom- 
plete did not do well. 



PROGNOSIS. 223 

In this list, however, are mixed up cases with and without 
suppuration, and also cases treated aseptieally and those ad- 
mitted with septic sinuses. In 31 cases there was never any 
suppuration, and none of these died, hut in 4 there was tuber- 
cular disease elsewhere (in 1 of these cases phthisis). In 3 of 
these cases the notes were incomplete, but the rest were 
either doing well, or had been cured when discharged. 

In 46 cases suppuration took place, and of these 6, or 13 per 
cent., died, and tubercular disease existed elsewhere in 10. Of 
these 46 cases, 1 was admitted in the fourth stage, for the 
cure of deformity, an abscess having previously healed, leaving 
45 cases to be considered. Of these, 29 were aseptic cases 
and 16 had septic sinuses. Of the 16 septic cases, 3, or 18'7 
per cent, died, and 8 were excised. Of the 29 aseptic cases 
3, or 10-3 per cent., died, all of tubercular meningitis, and 18 
were dismissed cured or much improved. 

Had I added more recent results, or included many cases not 
admitted to hospital, the proportion of recoveries would have 
been increased, but the above gives a very fair estimate of the 
prognosis under various circumstances. In any case the treat- 
ment must be persevered in for a long time : I have heard Mr. 
Thomas estimate the duration of treatment as 7 years with his 
splint, but that is probably excessive, certainly it is so when the 
more modern methods of treatment are employed. The signs 
of cure are disappearance of thickening about the joint, loss of 
rigidity and pain, and, where there is no anchylosis, recovery of 
a considerable amount of movement. Care must, however, be 
taken not to leave off retentive apparatus too soon, even after 
the disease is apparently well, on account of the great tendency to 
recurrence of flexion and adduction. The amount of shortening 
left depends on the stage of the disease when treatment was 
commenced, and is on an average, 1J to 2 inches ; of course, 
cases treated properly in the first stage may have no shortening. 
The shortening tends to increase for 3 or 4 years after recovery, 
the growth of the limb as a whole being somewhat retarded. 



224 DISEASE OF THE HIP JOINT. 

1. Treatment of the First Stage. 

In discussing this question, it will be best, even at the risk 
of some repetition, to consider the treatment in each of the four 
stages which have been described, rather than as a whole. The 
treatment naturally falls under two groups in each stage, 
expectant and operative. Expectant treatment consists of rest 
both as regards movement and muscular contraction, and of 
attention to the general health. 

During the first stage expectant treatment holds the first 
place, and operative treatment would only be thought of in 
quite exceptional cases. The. methods of expectant treatment 
consist either of extension or the employment of some suitable 
apparatus without extension. Whether extension is necessary 
or not will depend, first, on the degree of rigidity, i.e., of 
spasmodic contraction of the muscles surrounding the joint ; in 
other words, on whether the disease is primarily and purely 
synovial, or whether the bone is affected, in addition or alone ; 
and, secondly, on the amount of pain. 

Where the disease is purely synovial, and pain is not marked, 
then extension should not be employed, or if used the weight 
should be very light. In these cases, the muscular contraction 
is very slight, and the effect of extension would merely be to 
stretch and irritate the already inflamed capsule, and thus 
increase the inflammation without any corresponding advantage. 
The only reason for employing extension in these cases would 
be the presence of a certain amount of deformity, and it should 
be discontinued as soon as the deformity has been overcome. 
It is at this stage that Thomas's splint is especially useful. 
This splint is now well known, and I need only refer 
to it shortly. The splint consists of a long flat bar of 
wrought-iron, which runs straight down the back from just 
below the level of the axilla to the buttock. It then bends 
gradually forward, forming a concavity in which the buttock 
lies, and then is continued straight down behind the leg, the leg 



THOMAS'S HIP SPLINT. 225 

portion being parallel to the trunk portion, only lying on a more 
anterior plane on account of the bend forward to fit the buttock. 
Further, in order that the splint may apply itself properly, it is 
necessary to rotate the trunk part so that it may lie against the 
curved thorax ; in a right-sided splint the rotation is so that 
the anterior surface of the bar looks towards the left, and vice 
versa. This rotation is from the commencement of the buttock 
bend upwards. In the ordinary Thomas's splint there are three 
cross bars attached to the vertical bar, the wings on the side 
affected being shorter than those on the other. The upper 
wings grasp the body just below the axilla, the middle at the 
upper part of the thigh, and the lower at the lower part of the 
calf. On the healthy side the wing is applied closely to the 
body, but on the affected side it is opened out somewhat so as 
to allow the body to get away slightly from the bars on the 
other side. The splint is fastened to the body by a bandage at 
the upper part acting as shoulder braces, and by turns of band- 
age around the calf of the leg and turns around the middle of 
the thigh (see Fig. 40). 

Thomas gives the following rules for applying his splints : — 
" 1. The initial act should be, to place the machine so far 
posteriorly that it is just out of sight at the buttock part when 
the patient is lying horizontally. 2. The machine should be 
pushed upwards until the upper wings are close to the patient's 
axilla;. 3. An assistant should grasp the patient's leg together 
with the lower part of the main stem to hinder the machine 
from slipping downwards while the operator is manipulating it 
(i.e., twisting it so as to fit properly). 4. The surgeon should 
proceed first, to closely fit the wings which grasp the sound side 
of the trunk, thigh, then leg, and afterwards the other wings 
are adjusted. 5. The shoulder braces are to be adjusted, after- 
wards the thigh and leg bandages." 

Where flexion is present, the knee must not be tightly bound 
down on the splint, otherwise great pain may be occasioned; 
the leg will, in most cases, gradually sink on to the splint. 

15 



226 



DISEASE OF THE HIP JOINT. 



Indeed, if the flexion is marked, it may be well to place some 
soft pads in the hollow of the knee to give slight support, taking 
them away gradually as the leg becomes more extended. 

While flexion is overcome by this splint in many cases, and 
almost always in the first stage, the result is by no means so 
satisfactory as regards adduction and abduction, more especially 
adduction. Although the latter comes, as a rule, under the 




Fig. 40. — Single Thomas's splint applied. 

second stage, it will be most convenient to consider the whole 
matter of Thomas's splint here. Without some arrangement 
around the pelvis, the patient is able to move the pelvis from 
side to side, and thus escape the lateral action of the splint, and 
where abduction is present, he moves it to the sound side ; where 
there is adduction, it moves to the affected side. To avoid this, 
Thomas bends downwards one or other of the uppermost lateral 
wings so as to get a grasp on the pelvis (the sound side in 



THOMAS'S HIP SPLINT. 227 

abduction, the affected side in adduction), and also bends 
the middle bar upwards, but the result is not satisfactory, and 
in these cases he has found it necessary to add a half band at 
the level of the pelvis. In my experience it is best in all cases 
to employ a pelvic band similar to the other bands. In this 
way one can fix the pelvis to a certain extent, although it is 
marvellous what a child can do in the way of wriggling out of a 
position which is disagreeable. In young children I believe a 
double Thomas, with pelvic band, is much more efficient than a 
single Thomas, and is much more likely to overcome the adduc- 
tion, but even with that one does not get the exaggerated degree 
of abduction which, as I shall point out in considering the 
second stage, one desires to have. 

Even although fitted with this splint, the patient should not, 
as is frequently done, be at once provided with crutches and a 
patten on the sound side and allowed to walk about. On the 
contrary, he should be kept recumbent till all the acute 
symptoms have passed off, indeed till the condition of the joint 
is well advanced on the road to cure. JSTot uncommonly the 
first result of applying the splint, especially if there is no 
support under the knee, is a good deal of uneasiness and pain 
and disturbed nights, which may last for several days. This 
gradually subsides, and if the splint is readjusted from time 
to time as the deformity is overcome, the joint becomes quite 
easy. 

In cases where there is much rigidity of the joint and starting 
pains, I believe that the judicious employment of extension 
in the first instance is much better practice than the use of 
Thomas's or any other splint. Under these circumstances the 
contraction of the muscles around the joint is keeping the head 
of the femur pressed firmly against the upper and back part of 
the acetabulum, thus leading to atrophy of the articular 
cartilages at. that part and keeping up the inflammation in the 
bone, and it is of great importance to diminish this excessive 
pressure as far as possible. This is not properly done by means 



228 DISEASE OF THE HIP JOINT. 

of Thomas's splint, and is, I believe, best accomplished by 
moderate extension. It must be borne in mind that the object 
of the extension is simply to tire out the muscles and put a stop 
to their tonic contraction, and not to pull the bones apart. A 
good deal of the objection which has been made to the use of 
extension has been founded on the impression that heavy weights 
must be employed with the view of separating the bones, but 
such a procedure is both unnecessary and hurtful. As I have 
already mentioned, extension does harm when employed in 
cases of pure synovial disease without muscular rigidity by 
stretching the already inflamed capsule, and therefore when 
employed in cases of marked muscular contraction, the case 
must be closely watched, and the weight diminished or left 
off in favour say of Thomas's splint as soon as this contraction 
is overcome and the weight begins to tell on the capsule. This 
is generally indicated by increase of the pain or the occurrence 
of tenderness about the joint. 

In applying extension for hip-joint disease, it is best to apply 
the strapping (after shaving the limb) to the thigh from close 
to the hip-joint to the knee, but to avoid applying it to the 
leg below the knee. The reason for leaving the leg free is 
that when the extension is applied to the leg the knee-joint 
is apt to be damaged, especially if the weight is continued for 
some time, and more especially if there is any abduction or 
adduction to be overcome ; the ligaments become stretched, and 
there may be considerable looseness of the joint. Good ad- 
hesive strapping is employed, and after a turn of bandage has 
been placed over it, the end is turned down • and bandaged over. 
Where a good deal of weight is to be employed, it is well to 
fasten the vertical straps in the first instance with a few 
circular or oblique turns of strapping, and then the bandage 
outside this. In some cases the skin is too sensitive for 
strapping, in which case a vertical piece of bandage must be fixed 
on each side by circular turns of bandage, or when the transverse 
bar to be mentioned immediately is employed, the extension may 



EXTENSION—ACTUAL CAUTERY. 229 

be fastened to it. The body is kept at rest by sandbags, or 
if the patient is very restless, a Thomas's splint may be worn 
in addition to the extension. The line of extension should at 
first be in the direction of the deformity, the limb being 
gradually brought into the proper line. In the first instance, a 
weight of three to four pounds is usually sufficient for children, 
and this may be increased or diminished according to circum- 
stances. Further, in this stage the extension should ultimately 
be in the direction of slight abduction. It is well also to apply 
a broad bar of wood transversely behind the thigh, fixed on to it 
by plaster of Paris (the patella looking straight forward), so as 
by its leverage to oppose the tendency to rotation of the limb ; 
where this is employed, the friction is of course greatly in- 
creased, and more weight must therefore be used. As a rule, in 
the first stage of hip disease extension need not be employed 
after the muscular rigidity has passed off, and a properly fitting 
single or double Thomas's splint may then be substituted 
for it. In this stage, then, I believe that extension holds 
a secondary place to such forms of apparatus as Thomas's 
splint, Bonnet's wire cuirass (see Fig. 41), or best of all, 
Phelps' box. 

In the general remarks on treatment I have referred to the 
use of the actual cautery, and in a certain number of cases 
in adults this method of treatment has been of considerable 
benefit. The broad cautery is applied at white heat in a 
vertical direction in front of the joint and behind the trochanter, 
boracic poultices are then used till the slough separates, and 
then savin ointment, either pure or diluted with vaseline. 
The sores are kept open, if possible, for about six weeks, and 
then dressed with weak boracic ointment and allowed to 
heal. As a rule the use of extension is also indicated in these 
cases, and the two measures therefore generally go together. 

While the majority of cases of hip-joint disease, taken at this 
stage and treated carefully, recover, the prognosis in a certain 
number is not so favourable, and the question of early operation 



230 



DISEASE OF THE HIP JOINT. 



has to be taken into consideration. This is the case where 
there is a deposit in the neck of the femur, especially if it has 
not as yet infected the joint. The question also arises whether, 
after the joint has become infected, it might not be well in 
rapidly progressing cases to perform as 
complete an arthrectomy as possible. 
I have already mentioned on page 
183 a case in which a deposit was 
removed from the neck of the femur, 
and on page 208 I have indicated how 
the presence of these deposits may be 
recognised. Where there is distinct 
thickening about the trochanter and 
neck of the bone, without, as far as 
one can judge, any infection of the 
synovial membrane, the probability is 
that there is a deposit in the substance 
of the neck, and the proper treatment 
seems to be to make a vertical incision 
over the outer surface of the tro- 
chanter, chisel away the dense bone, 
and then scoop out the cancellous 
tissue in the direction of the neck 
till the deposit is reached (see case 
3, page 183). "Where the deposit is 
in its usual situation, and has infected 
the joint, if it is thought desirable to 
operate, it is best to open the joint 
by the usual anterior operation for 
excision, and thus one gets immediate 
access to the sequestrum. After 
removing this with a layer of the surrounding healthy bone, 
the synovial membrane should be clipped away as completely as 
possible, and an attempt made to get at the ligamentum teres by 
dislocating the head. In order to remove the posterior part of 




Fig. 41. — Bonnet's wire 
cuirass for hip-joint disease. 
This may also be used in 
cases of spinal disease. 
(After Bradford and 
Lovett.) 



TREATMENT OF THE SECOND STAGE. 231 

the capsule, it is necessary to make an oblique incision behind 
in the line of the fibres of the gluteus maximus, and by utilising 
both openings, the greater part of the affected tissues can be 
removed. I doubt, however, if in any case a really complete 
arthrectomy can be performed in the hip-joint, and therefore 
I would limit the operation just described to a few cases 
where the disease is advancing rapidly. The former operation 
(tunnelling the neck of the femur) is a much more satisfactory 
one, but it is very rarely that one meets with a case suitable for 
it. Hence, the field of the operative treatment of the first 
stage of hip disease is very limited. 

2. Treatment of the Second Stage. 

In this stage, especially in the early period, the relative posi- 
tion of splints and extension is the reverse of that in the first 
stage, and now, in my opinion, extension takes the first place 
among the means of expectant treatment. Wherever the disease 
may have begun the surface of the bone is now becoming carious, 
rarefying osteitis and absorption are going on, and are greatly 
aided by the tonic muscular contraction, and the rigidity of the 
joint is very much increased. This condition is better treated by 
extension, with the view of diminishing the muscular contraction 
and the consequent destruction of bone, than by means which 
merely aim at placing the joint at rest. The extension is 
applied in the same manner as has already been described, and 
it is of still more importance in this case than in the other to 
see that the extension acts on the thigh and not on the leg. 
In applying the extension it is of especial importance to over- 
come the adduction of the limb. In this stage there is already 
some actual shortening, and if the patient recovers with an 
adducted limb, the pelvis must be still more tilted upwards on 
the affected side in order that the leg may not cross the other, 
and thus the functional shortening is considerably increased. 
Indeed, it is best not merely to overcome the adduction, but to 



232 DISEASE OF THE HIP JOINT. 

produce a slight degree of abduction, so that when the patient 
walks he tilts his pelvis downwards on the affected side so as to 
bring the two legs parallel, and thus the functional shortening 
is diminished. This effect must be gradually produced ; to place 
the extension in the line of abduction at once causes too much 
pain, and it is best for the first two or three weeks to employ the 
extension in the line of the deformity, and then gradually to 
carry it outwards. In some cases, where the adductors are very 
short, it may be necessary to perform tenotomy, at any rate of 
the adductor longus tendon close to the pubis, in order to 
permit abduction. Further, it is necessary to fix the pelvis, 
otherwise it may follow the thigh and the adduction may 
remain. This is accomplished by means of a perineal band 
around the healthy side, attached to the top of the bed, or, if 
necessary, to a pulley and weight, a thick heavy sand-bag being 
also applied to the upper part of the pelvis on the affected side ; 
or it may be done by placing the patient on a Thomas's splint. 
"While in cases treated in the first stage one may hope for a 
more or less freely movable joint, this is not a thing to be 
aimed at in the second stage, and in the later period, where the 
articular cartilages are destroyed, anchylosis (fibrous or bony) 
will usually occur, and it is therefore of great importance that 
this should be in as favourable a position as possible. 

It is necessary to keep up the extension for a longer period 
than in the early stage of the disease, in fact, till the acute 
symptoms have come to a standstill and a certain amount of 
consolidation has occurred, unless, indeed, any indication, such 
as increase of pain, &c, has arisen to lead to its discontinuance 
at an earlier period. The chief objection to extension is the 
confinement to bed, but even with Thomas's splint, Thomas 
himself advises that patients should be kept in bed and not 
allowed to get about till the disease is in a fair way to recovery. 
The bad effect of confinement to bed is much exaggerated ; the 
health of patients confined to bed, but free from pain, and with 
the disease improving, is a great deal better than that of those 



APPARATUS DURING THE SECOND STAGE. 233 

who are allowed to get about, who suffer pain, and whose 
disease does not improve ; and extension by relieving pain and 
stopping the destructive process leads to rapid recovery of 
appetite and of the general health. Nevertheless, there conies 
a time when matters will progress more quickly if the patient 
can get out into the open air without injury to the joint, and 
therefore the question ultimately arises of substituting some 
other apparatus for the weight and pulley extension. 

The first apparatus that one naturally thinks of is Thomas's 
splint, and many surgeons advocate its use not merely in the 
early stage of the disease, but at all stages. My experience, 
however, is that where there is much adduction, one cannot 
overcome it satisfactorily by this splint, and one cannot produce 
distinct abduction at all. Even where the adduction has been 
overcome for the time being by extension in the abducted posi- 
tion, unless the extension has been continued till more or less 
consolidation has occurred, there is still a strong tendency to 
recurrence of the adduction on leaving it off. If a Thomas's 
splint is employed, it must have a pelvic band, so as to fix the 
pelvis, which otherwise shifts on the splint, and prevents any 
action in the way of abduction. Even with a pelvic band, and 
with the bending downwards of the upper wing, it is remarkable 
how a child manages to escape from an irksome position. In 
cases where I have wanted to get distinct abduction, I have had 
the splint bent somewhat outwards at the hip curve, and though 
this has answered better, I cannot say that I have been satisfied 
with the arrangement. Much better than the single Thomas's 
splint at this stage of the disease is the double Thomas with 
pelvic band. In this way the pelvis can be much more securely 
fixed and the adduction more easily prevented, and this is an 
arrangement which I frequently employ at this stage while the 
disease is active. Perhaps the best of all the forms of apparatus, 
in many cases, is the Phelps' box, which I shall describe in connec- 
tion with spinal disease. By having the leg piece on the affected 
side 3 to 4 inches longer than the leg, extension can be readily 



234 DISEASE OF THE HIP JOINT. 

kept up by means of elastic bands fastened to the strapping 
on the one hand, and the foot-piece on the other, the amount of 
extension being graduated by the degree of tension of the bands. 
In this way the patient can be taken out in the open air when- 
ever it is deemed desirable without interfering with the local 
treatment. 

Another good arrangement is Bonnet's wire cuirass, of which 
Fig. 41 is a drawing which explains itself. In America the 
favourite method of treatment is by means of so-called " trac- 
tion " splints, which essentially consist of an arrangement 
grasping the thigh and leg, and, moving on this by means 
of rack and pinion, an upper part with an internal band or 
bands getting a purchase on the tuber ischii and the perineum. 
The one most commonly employed is the Davis-Taylor traction 
splint. The objection to these splints is the pressure on the 
perineum, which is very apt to lead to ulceration. The other 
forms of apparatus, metal or leather splints, and plaster of 
Paris, are inferior, but encasing the trunk and both limbs in 
plaster of Paris may be useful in some cases of advanced dis- 
ease with sinuses, openings being, of course, left for dressing 
the latter. 

In some cases, especially where the bone is thickened and the 
pain great, the combination of the actual cautery with the 
extension is of evident service. The best situations for the 
cautery wounds are in front of the joint just inside the line of 
incision for the anterior operation of excision, and behind the 
trochanter. It is best to apply it in both places at the same 
time, and to make the sores about an inch in breadth and 3 
inches in length. The iron is brought to a white heat, and 
passed two or three times rapidly over the part. Boracic 
fomentations are employed till the slough separates, and then 
the sores are dressed with savin ointment, pure or diluted, and 
kept open for about six weeks. Should they tend to heal sooner 
it is well to apply nitrate of silver to them, or to open them up 
with potassa fusa. 



OPERATION DURING THE SECOND STAGE. 235 

During this stage the question of operation also arises, and 
opinions are very conflicting on this point. I have already 
referred to the question of arthrectomy in speaking of the first 
stage of the disease, and my remarks apply equally to similar 
cases not seen till they have passed on to the second stage. A 
good deal has of late been written in favour of early excision in 
hip-joint disease, and some surgeons advocate it very strongly. 
The word " early " applies to operation before visible abscesses 
have formed, that is to say, operation during the second stage, 
and not to operation during what I have described as the first 
stage; very few surgeons would approve of excision at that 
period of the disease. 

The advantages claimed for excision at this stage are rapid 
recovery, the getting rid of a source of general infection, and 
the removal of sequestra, especially from the acetabulum. The 
disadvantages urged are the risk of the operation, especially 
of shock, the risk of dissemination of the disease, imperfect 
recovery, bad functional result, and interference with growth. 
We may consider these points in detail. 

As regards the question of rapid recovery, we must not lose 
sight of the fact that- where the disease is extensive and the 
patient weakly there is a considerable element of risk in a 
thorough operation, and, unless the operation is thorough, 
recurrence is very apt to take place. I have in two instances 
lost patients from shock after excision, but in both of these 
the disease was in the third stage, large abscesses being 
also present, which had to be treated. I also know of 
similar cases in the practice of others, and therefore the 
operation of itself cannot by any means be looked on as one 
free from risk, especially in the later stages of the disease. 
"Where, however, the patient gets over the shock of the 
operation, the wounds, if kept aseptic, heal by first intention, 
and in a considerable proportion of eases remain soundly 
healed. It is, however, a very difficult matter to thoroughly 
remove the whole of the affected synovial membrane, and 



236 DISEASE OF THE HIP JOINT. 

consequently in a certain number of cases where the disease 
is rapidly progressing the wound, which at first seemed 
soundly healed, breaks down at some point, and a sinus is 
formed, which may remain open for a long time, necessitating 
the use of a splint; or the divided surface of the bone may 
be again attacked and fresh operative procedures be required. 
From this point of view, therefore, while in a considerable 
number of cases, no doubt, recovery is greatly expedited, there 
must always remain a certain proportion in which no material 
advantage is gained. 

As to the diminution of the risk of general infection by 
operation at this stage, I am inclined to think that the advantage 
gained, if any, is not very great, and that for the reason which 
I have already mentioned, viz. — that it is almost impossible to 
remove the diseased synovial membrane completely. Indeed, 
in some cases it seems as if tubercular meningitis had been 
precipitated by excision. Konig states that of 18 cases of tuber- 
cular meningitis, 16 occurred after operation. Metaxas and 
Verchere, in the statistics of 55 cases of tubercular meningitis 
after operation, found that a large number, more than half, 
occurred after excision or scraping synovial membrane and 
abscesses. In my statistics I find 7 cases of tubercular menin- 
gitis after operation, chiefly excision of the hip, and of these 1 
(commencing ten days after operation), and in all probability 2, 
were undoubtedly due to the operation. Since these statistics 
were drawn up I have had another case, and I know of another 
where tubercular meningitis directly followed excision of the 
hip. And if in a certain number of- cases tubercular menin- 
gitis may be set up, it follows that there must be a larger 
number in which a smaller quantity of the tubercular material 
gets into the blood and sets up deposits in other parts of 
the body. The risk of forcing tubercular material into 
the blood is greatest where the joint is scraped out, and, 
owing to the difficulty of removing the whole of the synovial 
membrane, one is very tempted to scrape the surface. In 



ADVISABILITY OF EXCISION. 237 

examining the question of the occurrence of phthisis after 
operation on tubercular joints, Middeldorpf found that phthisis 
was the cause of death in 16 per cent, of those amputated, 14 
per cent, of those excised, and 3077 per cent of those in which 
caseous deposits were scraped out. Looking at all the facts, 
I do not think that the possibility of preventing further 
infection by early excision need be of itself a great inducement 
to operation. 

The chief objections which I have to excision of the hip at an 
early period before it is absolutely necessary for the cure of the 
disease are, the imperfect functional result and the interference 
with the growth of the limb. After excision of the hip, the 
patient is in much the same condition as one who has a con- 
genital dislocation of the hip; the trochanter slides up and 
down over the side of the pelvis during walking, and the patient 
does not have the same firm support that he has where 
anchylosis has taken place in a good position. No doubt the 
amount of sliding varies a good deal in different cases, and is 
much less if the patient is not allowed to bear weight on the 
limb for six or eight months after the operation. Nevertheless 
the support is not a strong one, and I hardly think the 
mobility of the limb after excision compensates for the weaker 
support. Indeed, some surgeons who advocate early excision 
take means to obtain anchylosis by pegging the neck of the bone 
to the acetabulum, or to get the support of a buttress of bone in 
cases where the margin of the acetabulum is removed by raising 
a piece of bone and periosteum from above the acetabulum and 
making it project above the neck of the bone. 

The other objection is. the interference with the growth of the 
bone. Opinions vary considerably as to the amount of shorten- 
ing after excision as compared with that following recovery 
without operation, but it is generally admitted that there is 
more shortening after excision. Where the disease has gone on 
to the second stage, there is almost always a certain amount of 
shortening after recovery without operation, due to enlargement 



238 DISEASE OF THE HIP JOINT. 

of the acetabulum, to absorption of the head and neck of the 
femur, to destruction of the epiphysis between the head and 
neck, to deficient growth of the limb from premature ossifica- 
tion of the upper epiphyses, to imperfect use or some reflex 
trophic disturbance, or to several of these causes combined. 
Where the disease has begun say about seven years of age, and 
has passed on to the second stage, it will generally be found, 
when the patient has reached his full growth, that there is an 
average of 1 J to 2 inches of shortening. Where, under similar 
circumstances, excision has been performed, the shortening 
is greater, from 2 to 3 inches, and sometimes more. It 
seems to be greatest in those cases where the trochanter has 
also been removed, and, in one instance which I have seen, 
where the head and trochanter had been removed in a child 
cet. 4 \, there was no less than 11 inches of shortening at the 
age of 16, growth having apparently been much interfered with 
throughout the whole of the extremity. It is difficult to say 
why the shortening should be greater after excision than in 
cases which recover without operation, but in which, without 
doubt, the epiphysial line between the head and neck of the bone 
has been much injured by the disease. I believe that it is a 
trophic effect, and that in excision with removal of the synovial 
membrane there is some more serious interference with the 
trophic nerves of the femur than results from the disease alone. 
I have already pointed out that in all probability the rapid 
atrophy of the muscles around an inflamed (not necessarily 
tubercular) joint is the result either of a neuritis or of some 
reflex phenomenon, and that similar trophic disturbances are 
intensified after operation is well seen after excision of the 
elbow joint, where we not uncommonly find that the pulse 
on the excised side is weaker than on the other, that there 
is increased growth of nails and hair, increased secretion of 
sweat, &c. 

Taking all these facts into consideration, and bearing in mind 
the large proportion of recoveries at this stage by suitable non- 



TREATMENT OF THE THIRD STAGE. 239 

operative measures, I think that excision ought only to be an 
exceptional method of treatment, and not by any means the 
rule. There are certain cases, however, in which I think it is 
right to intervene during this stage by excision. For example — 
1. Where the disease is evidently progressing rapidly, where 
tenderness does not subside under treatment, where the fulness 
in the groin increases, where starting at night continues, and 
where the shortening rapidly extends. 2. Where with increase 
or persistence of the symptoms it is evident that there has been 
primary acetabular disease, as shown especially by thickening 
of the tissues on the inner surface of the acetabulum as felt per 
rectum. In such a case the head of the bone must be removed 
before sufficiently free access can be got to the acetabulum. 
3. Where true dislocation has occurred, especially where the 
head of the bone cannot be subsequently kept in its place 
satisfactorily. 

3. Treatment of the Third Stage. 

The essential feature of this stage is the presence of unopened 
abscesses or of sinuses, and these, as I have already mentioned, 
may arise in various ways. Taking first cases with unopened 
abscesses, I may remark that the presence of pus complicates 
matters very considerably, and necessitates the employment of 
some form of operative treatment. The time has passed when 
abscesses may be left in the hope of their absorption ; they should 
always be treated as soon as detected. The main question to 
be considered is whether we should treat the abscess alone on 
the principles previously referred to, or whether we should, as 
is the opinion of a good many surgeons, at once proceed to 
excision of the joint. In this we must, of course, be guided by 
the condition of the individual case, and no doubt in a certain 
number of these cases excision will be necessary, but, as a rule, 
I believe it is best where the abscess is in the thigh or buttock — 
extrapelvic in fact — to treat it alone without excising the joint 



240 DISEASE OF THE HIP JOINT. 

in the first instance, and that for various reasons. In the first 
place the presence of an abscess does not render the case by 
any means so hopeless as some surgeons think, provided it is 
treated aseptically. I have already mentioned a list of 29 
cases of unopened abscesses connected with the hip-joint 
which were treated in the first instance by aseptic drainage. 
Of these 4 were excised before the wound had healed, and of 
the remaining 25, 18 or 72 per cent, were cured without 
further operation, 5 others were doing well but still under treat- 
ment, and 2 were not doing well, having become septic. Since 
the introduction of the more recent methods of treating chronic 
abscesses the results have been very much better, and almost 
all the cases which I have treated in this way have healed. 
We get this advantage by treating the abscess alone in the first 
instance, that the cases are brought back again to the second 
stage, and a considerable number recover without excision. 
Even where excision is necessary the operation is less extensive, 
and, therefore, less dangerous from shock if the abscess has been 
got rid of in the first instance. Where, in addition to excision, 
especially where there is extensive disease of the pelvis, one 
has to remove large abscesses, the patients, who are often at 
this stage in a feeble condition, suffer greatly from shock and 
may even die of it as has happened to me in two instances. 

I have already described the more recent methods of treating 
chronic abscesses, and in the case of abscess connected with 
the hip-joint one can frequently remove a large portion of the 
wall by dissection, especially where the abscess is on the 
anterior and outer surface of the thigh. A long incision is 
made over the abscess, the wall exposed and carefully separated, 
without opening it, to as great an extent as possible. It is 
then cut off at the deeper part, the contents carefully washed 
away, and the further connections of the abscess examined. It 
will generally be found to pass into the joint at some part 
often, however, through a very narrow canal. A probe passed 
along this canal will ascertain whether there is any sequestrum, 



TREATMENT OF ABSCESSES. 241 

and if there is it can be removed after dilatation of the opening 
in the capsule. If no sequestrum is felt, then, I think, it is best 
not to dilate the communication with the joint at this time, 
but to thoroughly scrape and peel away the remains of the 
abscess wall outside, fill the wound with iodoform and glycerine 
and stitch it up. Where the abscess is deep-seated it is best 
to lay it freely open, and then holding the wound apart peel 
off the wall as far as possible, scraping away the remainder 
with the flushing spoon. It is far better to make too large 
incisions in the skin than too small ones. We must see 
thoroughly what we are about, and as the skin incision is not 
in a noticeable place and heals by first intention, a little extra 
length is of no consequence. 

Where we have to do with abscesses which have originated 
in the pelvis in connection with disease of the acetabulum, 
excision of the head of the bone at once is usually the best 
practice. After removal of the head of the bone the acetabulum 
is perforated, and a free opening made through it into the 
pelvic abscess. Where the abscess is also projecting in the 
iliac fossa, it is well to begin by making an incision into it at 
that point, because in that way one gets better access to the 
cavity to scrape it out. After the operation iodoform and 
glycerine solution is injected and all the wounds stitched up, 
pressure being applied over the region of the hip. 

By treating the abscesses in this way, and employing the 
other methods recommended for the second stage, further 
operation becomes unnecessary in a considerable number of 
cases, but the instances in which excision is required are more 
frequent than in the second stage of the disease. A good many 
of the cases which come under observation at this period have 
been neglected and allowed to get into very bad positions, 
which can only be properly remedied by excision. Again, the 
destructive changes about the joint are frequently more ex- 
tensive, loose sequestra are present, and the diseased tissues 
tend more to caseate and less to recovery. In a certain 

16 



242 DISEASE OF THE HIP JOINT. 

number of cases with abscesses treated as above, the wound 
which in the first instance may have healed by first intention 
breaks down at some part, a sinus is established and excision 
may be necessary. In any case the operation of excision is 
much less extensive, and consequently less dangerous if the 
great bulk of the abscess is first got rid of in the manner 
just described. 

Where septic sinuses are present the conditions are alto- 
gether less favourable. No doubt, even although there are 
sinuses, a certain number of cases recover if they are properly 
drained, and if the joint is thoroughly fixed for a sufficient 
length of time. But, under these circumstances, suppuration is 
very apt to go on, and lead to waxy degeneration of internal 
organs, or death from hectic fever or exhaustion, or fresh 
abscesses form, and some septic complication may occur. 
Further, as I have already pointed out, the presence of sepsis 
interferes with the recovery of the tubercular disease, and in 
fact leads to its extension locally, and also aids its dissemina- 
tion throughout the body. Hence, where septic sinuses are 
present, I believe that in most cases it is advisable to adopt 
some form of operative treatment. The mildest treatment, 
which is not unfrequently successful, is to enlarge the opening 
of the sinuses, scrape and wash them out, removing at the same 
time any sequestrum of bone which may be felt, sponge the 
surface with undiluted carbolic acid, and stuff daily with 
cyanide gauze powdered with iodoform or soaked in balsam of 
Peru. By adopting these measures some of the cases heal 
without further trouble, and if not, the septic condition is much 
diminished and sometimes entirely abolished. Where healing 
does not occur, or where other reasons exist, excision will be 
required. The incisions for excision must in some cases be 
irregular, so as to give easy access to the sinuses, but I prefer, 
if possible, either the anterior incision or a vertical one over 
the centre of the outer surface of the great trochanter. Where 
there is marked displacement, or much disease of the aceta- 



OPERATION OF EXCISION. 243 

bulum, a curved incision behind the trochanter is often the 
most useful. 

The anterior incision begins just below the anterior superior 
spine of the ilium, and passes downwards and slightly in- 
wards along the anterior border of the tensor fasciae femoris 
for 3 to 4 inches. After dividing the skin and fascia the 
sartorius is drawn inwards, and the tensor fascia? femoris out- 
wards, and then a branch of the external circumflex generally 
crosses the middle of the wound, and must be divided. 
Separation is then effected between the gluteus minimus and 
the psoas and iliacus muscles, and the outer part of the capsule 
of the joint is exposed. On dividing this the neck of the bone 
is reached, and sawn through. Usually after dividing the neck 
there is no difficulty in children in removing the head of the 
bone and fairly free access to the cavity of the joint is obtained. 
By carefully pushing forward the vessels and the tendon of the 
psoas and iliacus there is not usually any difficulty in clipping 
away the anterior part of the synovial membrane. The remains 
of the ligamentum teres and any soft tissue in the acetabulum 
are then removed, and any carious portions of the pelvis 
attended to. As regards the posterior part of the capsule, it 
is difficult to clip it away without a posterior incision, and if 
only the anterior incision is employed, resort must usually be 
had to the sharp spoon. As portions of tubercular tissue must 
in most cases be left, I fill the wound with the 10 per cent, 
iodoform and glycerine emulsion, and where the skin was 
previously unbroken stitch it up without a drainage tube, and 
apply pressure especially over the anterior part of the joint. 
All antiseptic precautions must of course be taken, and it is 
well to take measures to prevent eversion of the limb. This is 
conveniently done by taking a flat splint about 10 inches long, 
placing it transversely behind the thigh, so that when it lies 
flat on the bed the patella looks directly forward. This splint 
is attached to the thigh by plaster of Paris, and has such a long 
leverage that the leg cannot rotate. The limb should be placed 



244 DISEASE OF THE HIP JOINT. 

in a distinctly abducted position, partly to bring the neck of the 
bone into the remains of the acetabulum, and partly in order 
that, should anchylosis occur more or less completely, it will 
be necessary for the patient, in placing the foot flat on the 
ground, to tilt the pelvis downwards on the affected side, 
and thus diminish the practical shortening. When the wound 
has healed the patient should be kept in bed for 6 or 8 weeks, 
and then fitted with a Thomas's splint and crutches, and not 
allowed to bear any weight on the limb for at least 6 or 8 
months. 

Another way of gaining access to the joint in children where 
the trochanteric part of the neck is affected, is by a vertical 
incision over the middle of the outer surface of the trochanter, 
commencing about 1£ inches above its tip, and extending down- 
wards for about 4 inches. The incision passes straight down to 
the bone, and through the cartilaginous trochanter, which is 
split into two parts and, the periosteum being divided trans- 
versely on the outer surface at the lower part, turned to each 
side. The neck of the bone is then sawn through obliquely at 
the outer part, and the head and neck extracted. By this 
incision, however, it is not possible to deal thoroughly with 
the capsule, and the epiphysial line of the trochanter is 
injured. 

A third incision which gives good access is that introduced by 
Sayre. It commences just above the trochanter, curves back- 
wards over its posterior surface, and then forwards again on to 
the outer surface of the femur. The semilunar flap is then dis- 
sected forwards, and the posterior part lifted from the bone. 
The posterior surface of the neck is thus exposed, and can be 
sawn or chiselled through, and good access is obtained to the 
acetabulum, better than by the anterior incision. If it is 
necessary to remove the trochanter, then in turning the anterior 
flap forwards, the periosteum with the attached muscles is peeled 
off the trochanter, the periosteum having been divided trans- 
versely at the point where the bone is to be sawn. The removal 



EXCISION OF THE JOINT. 245 

of the trochanter is, however, a serious matter, and should not 
be done unless absolutely necessary on account of disease. 

In all the forms where the skin was previously unbroken, 
the wound may be completely stitched up as before described, 
and pressure applied by means of sponges incorporated with 
the dressing, but where septic sinuses are present, I think 
it is best, after thoroughly scraping out the sinuses, to apply 
undiluted carbolic acid to the whole surface of the wound, and 
to stuff the wound for some days with cyanide gauze, impreg- 
nated with iodoform. After a few days (say 10 days), when 
granulation has taken place, if the wound is not suppurating, 
the stuffing may be left out and the wound allowed to close, 
or if suppuration is going on, the gauze may be impregnated 
with balsam of Peru instead of iodoform. This stuffing of 
tubercular wounds and sinuses with iodoformed gauze is a 
distinct advance on former methods of treatment, and wounds 
which previously would not heal at all often show marked 
improvement on adopting this method. 

In some bad cases of hip disease at this stage, where the 
patients are going down hill, where the sinuses are numerous, 
and where the bone disease is evidently extensive, amputation 
at the hip-joint has been recommended. I think that such 
treatment is very rarely indeed indicated, for even though the 
limb is removed, the pelvic disease still remains and may 
require treatment by subsequent operations. No doubt there 
is the advantage that the removal of the limb takes away a 
great source of pain and trouble to the patient, and, should he 
survive the operation, enables him to get about on crutches 
and thus get the benefit of exercise and fresh air. Mr. Howse 
has advised that in the first instance amputation at the knee 
should be practised, with the view of getting rid of the weight 
of the limb and enabling the patient to get about, and then the 
subsequent amputation at the hip, if necessary, would be less 
dangerous. I have not yet come across a case where I have 
deemed it advisable to perform either of these operations. 



246 DISEASE OF THE HIP JOINT. 

4. Treatment of the Fourth Stage. 

During this stage recovery with or without anchylosis is 
occurring, and generally nothing more requires to be done 
than to continue the expectant treatment with suitable 
retentive apparatus. Nevertheless, it sometimes becomes 
necessary to intervene at this stage on account of the occur- 
rence of abscesses, of the presence of sinuses, or of deformity 
which cannot be overcome without operation. 

Where abscesses are present at this stage, they should be 
treated as described before under the treatment of the third 
stage, great care being taken not to strain the joint, nor break 
up any [anchylosis. A free incision is made over the abscess, 
and as much of the wall dissected or peeled away as possible, 
the remainder being thoroughly scraped with the flushing 
spoon. 

Where sinuses are present, they may usually be left alone 
unless there is much discharge from them, boracic ointment 
and lint being used as a dressing. If, however, there is much 
discharge, they must be laid freely open, thoroughly scraped 
out, any sequestra removed, sponged with undiluted carbolic 
acid, and packed with cyanide gauze impregnated with iodoform, 
or later with balsam of Peru. 

Where there is much deformity (usually either adduction or 
rotation outwards), which, if anchylosis is, or has been, taking 
place, cannot be overcome with apparatus, we must do something 
in the way of operative treatment. Where there is marked 
adduction and no bony anchylosis, it is sometimes sufficient 
to divide the adductors and pull the leg outwards, keeping 
up and increasing the abduction afterwards by extension, so 
arranged as to pull the thigh and leg outwards. Where 
anchylosis has occurred, then the deformity may be remedied 
by excision, by dividing the neck of the bone, by taking a 
wedge out of the neck of the bone, or by Gant's method of 
dividing the bone below the trochanters. Where only one hip- 



TREATMENT OF THE FOURTH STAGE. 247 

joint is affected, I think the most satisfactory result is obtained 
by taking a wedge out of the neck of the bone, the base of 
the wedge being upwards in adduction or forwards in rotation 
outwards : this is most easily done by the anterior incision 
for excision. Afterwards it is best to try for bony union again. 
In some cases, however, Gant's plan is the best. Where both 
hip-joints are affected, and we have the condition of cross- 
legged deformity, then I think the result is most satisfactory 
where one joint is excised in order to get a movable joint, 
and allow the patient to sit, &c, and where a wedge is taken 
on the other side or the femur divided, so as to leave one 
side firm for walking. No doubt the immediate result after 
excision of both hips is not altogether unsatisfactory, but as 
time goes on the same troubles are apt to arise as in congenital 
dislocation of both hip-joints. 

I have here only spoken of the local treatment, and I need 
hardly say that there is no one method which is suitable for 
all cases. Each case must be carefully studied by itself, and 
treatment adopted according to the way in which it goes on. 
As to general treatment, I have already spoken of that 
sufficiently in Chapter XL, and need not repeat what was said 
there. 



CHAPTER XVII. 

DISEASE OF THE KNEE JOINT. 

In patients of all ages affected with tubercular diseases of 
bones and joints, the knee-joint is the second most frequent 
seat of disease, the spine coming first with 23 '2 per cent, of the 
whole, the knee-joint next with 16'5 per cent., and then the 
hip with 14'8 per cent. In childhood, however, the hip takes 
the second place with, in my statistics at Paddington Green 
Children's Hospital, 231 per cent., and the knee-joint third 
with 12 - 6 per cent., the ratio altering afterwards in favour of 
the knee. Disease of the knee-joint, therefore, is more a disease 
of adult life than that of the hip, but nevertheless it commences 
most frequently in the first decade. Thus, in my statistics of 
the total number of cases of knee-joint disease, 42 per cent, 
commenced during the first decade, 26 per cent, during the 
second, 14 per cent, during the third, and 10 per cent, during 
the fourth. Compare this with the periods of commencement 
of hip-joint disease. The comparison is more striking when 
we consider that, of the total number of cases of tubercular 
disease of bones and joints commencing during the first decade, 
30 per cent, were cases of hip-joint disease, and 29 per cent, 
cases of knee-joint disease; during the second decade, 20 per 
cent, hip, 23 per cent, knee; during the third decade, 5 per 
cent, hip, 18 per cent, knee ; during the fourth decade, no case 
of hip-joint disease, 37 per cent. knee. 

In this joint the disease commences more frequently in the 
synovial membrane than is the case in the hip-joint, but the 
frequency apparently varies at different ages. The following 
table, constructed from Willemer's paper, shows the results 



PATHOLOGY OF KNEE JOINT DISEASE. 249 

obtained as to the primary seat of the disease at various ages, 
and the nature of the osseous deposits : — 





1 to 10 Years. 


11 to 20 Years. 


Above 20 Years. 


Sequestra, . 


Per cent. 
19-4 


Per cent. 
19 


Per cent. 
49 


Caseous bone deposits. 


41-6 


32 


16 


Pure synovial disease, . 


38-8 


49 


33 



I need not go into other statistics, as these represent fairly 
the results obtained. The important points are the great in- 
crease in the frequency of sequestra as compared with soft 
deposits in advanced life, the conditions over 20 being practi- 
cally the reverse of those under 10. Another important point 
is the diminution in frequency of pure synovial disease in 
advanced life as compared with the second decade, where it 
attains its maximum. 

The situation of the osseous deposits varies considerably, but 
they occur by far most frequently in the epiphyses of the 
femur and tibia. In none of the specimens which I have cut 
has a deposit been found on the diaphysial side of the epi- 
physial line, but I have seen bottle specimens showing this, 
and Konig states that it sometimes occurs in children, especi- 
ally in the form of soft deposits. As to the parts most com- 
monly affected, these deposits occur generally, as in the case 
of other bones and joints, in the most exposed parts of the 
bone, and also in the neighbourhood of the points of attach- 
ment of tendons. In the knee-joint the lower end of the 
femur, more especially the internal condyle, is most usually 
primarily affected, then the head of the tibia, and very much 



250 DISEASE OF THE KNEE JOINT. 

more rarely the patella. It is not at all uncommon for the 
primary osseous deposit to be quite small, and situated im- 
mediately beneath the articular cartilage, which it destroys 
and thus effects a communication with the joint; in these 
cases, also, the ■ deposits are often multiple. The more deeply 
placed deposits may also make their way into the joint, or 
they may, especially in the tibia when extra-epiphysial, and 
also when situated towards the posterior and upper part of the 
condyles of the femur, form a. communication with the surface 
outside the capsule, and lead to the production of extra- 
articular abscesses. It is in this joint, also, that Kocher thinks 
he has observed primary disease of the fibro-cartilages. 

I have so frequently referred to the knee-joint in describing 
the tubercular diseases of synovial membrane and bone that it 
would only be repetition if I were to go into details here. I 
have already referred to the results which follow the bursting 
of these abscesses into the joint, to the various forms of disease 
of the synovial membrane, to the changes in the bone as the 
result of the deposits, of the caries, &c. We have also, as in 
the hip, pressure effects and tendency to displacement, more 
especially flexion and backward displacement of the leg. This 
is the joint in which some of the rarer forms of the disease 
most frequently occur, such as the localised tubercular growths, 
hydrops tuberculosus, &c. Caries sicca is rare in the knee- 
joint, but Konig states that he has met with it, especially in 
young individuals, and that it presents all the characteristic 
appearances formerly described. 

Symptoms of Knee Joint Disease. 

The symptoms vary, of course, according to the pathological 
condition, and as this can be more easily made out in the knee- 
joint than in the hip, it is best, instead of dividing the symptoms 
into various stages, to consider them in reference to the actual 
state of matters in the joint. 



LOCALISED SYNOVIAL DISEASE. 251 

1. Localised Synovial Disease. 

A rare condition, but one which it is well to bear in mind, is 
the localised tubercular deposit in the synovial membrane. 
This may occur in two forms : — (1) a localised thickening of 
the synovial capsule, and (2) one or more pedunculated tubercular 
tumours hanging into the joint. The former condition is very 
rarely seen, because though no doubt a good many cases begin 
in that way, advice is seldom sought till the disease has spread 
over the whole or the greater part of the capsule. I have seen 
one such case some years ago before I realised the value of early 
operation, and I then watched the thickening rapidly extending 
over the whole joint. The pedunculated tumours are not so 
uncommonly met with, because the disease seems to be more 
localised, but here also after a time the whole synovial membrane 
becomes affected, and it is not at all uncommon to meet with 
these pedunculated masses in operating on advanced cases. 
The symptoms which these swellings give rise to are incon- 
venience in moving the joint, the sensation of a foreign body 
inside it sometimes causing sudden pain and, where the nodule 
is in the usual place, viz. — the suprapatellar pouch, the presence 
of a swelling. Very commonly, also, if the patient has been 
using the joint much, there is effusion into it, and it is only 
when this fluid has become absorbed by rest or been removed 
by tapping that the nodule is felt. Under such circumstances 
it is not always easy to make the diagnosis from an attached 
loose cartilage, but as regards the local condition, the most 
important points are — first, the size of the swelling, the 
tubercular nodules being larger than the attached cartilages ; 
and secondly, the presence of some thickening of the synovial 
membrane in the vicinity. One is further guided in 
making the diagnosis by the history of previous tubercular 
disease elsewhere, or the co-existence of other tubercular 
lesions. 



252 DISEASE OF THE KNEE JOINT. 

2. Diffuse Primary Synovial Disease. 

Generally, when the patient comes under observation, the 
synovial membrane has become affected all over, though, per- 
haps, more in one place than in another. In describing the 
characters of primary synovial disease, it is well to consider it 
under two stages, the first where the disease is still limited to 
the synovial membrane, and the second where other structures 
in the joint have become secondarily involved. 




Fig. 42. — Synovial disease of the right knee joint, showing the 
great swelling co-extensive with the synovial capsule. 

1. In the early stage of synovial disease the patient usually 
makes very little complaint. He limps a little, but his chief 
complaint is that his leg feels tired after slight exertion and is 
somewhat stiff, and on looking at his knee he notices that it is 
swollen (see Fig. 42). As time goes on the swelling increases, 



DIFFUSE SYNOVIAL THICKENING. 253 

and also the stiffness, but it is often remarkable what a degree 
of movement may remain in this stage of the disease in spite of 
marked synovial thickening. On examination of the joint the 
synovial membrane is found diffusely thickened, sometimes more 
at one part than another, the thickening varying much in 
different cases. The thickened membrane has a boggy, elastic 
feel, and the swelling is most marked at the point of reflection 
of the synovial membrane on to the bones, where a thick mass 
of tissue may be felt rolling under the fingers. On looking at 
the knee also the condyles of the femur appear to be enlarged, 
especially the internal condyle, and on superficial examination 
one is very apt to think that the bone is affected. This is clue 
to the thickening of the lateral pouch of the synovial membrane, 
which spreads over the inner side of the internal condyle nearly 
to the back, and it will be found, on removing the whole of the 
synovial membrane, that the apparent thickening of the internal 
condyle has disappeared. It is sometimes difficult to be quite 
certain, without operation, in these cases whether or not there is 
disease in the internal condyle, but the following are the leading 
points in the diagnosis. In the pure synovial thickening, though 
there may be a little tenderness on pressure over the condyle, 
this is not usually marked, and the whole synovial membrane 
is thickened, but without much pain on movement or marked 
rigidity. In the case of primary disease in the internal condyle 
in the early stage, there is usually no general synovial thicken- 
ing, while the pain and tenderness about the internal condyle 
are more distinct. At a later stage of the bone trouble, where 
the synovial membrane has become diffusely thickened, there is 
usually marked tenderness over the condyle, chiefly at some one 
spot, and great pain on attempting to move the joint and marked 
rigidity. In the early stage there is not uncommonly some 
serous effusion into the joint, and when that disappears it is 
noticed that the synovial membrane is becoming thick. During 
this stage the general health does not materially suffer, though 
the patient may be somewhat pale. 



254 DISEASE OF THE KNEE JOINT. 

2. As time goes on the disease spreads to other structures 
of the joint, and we come to the second stage. As I have 
pointed out in the general pathology of synovial disease, the 
tubercular synovial membrane attacks the articular cartilage 
at the edges, and gradually spreads over the surface, and also 
to a slight extent underneath it. Spreading in this way, it 
destroys the cartilage, more at some parts than at others, 
leading to a perforated appearance, while at the same time the 
bone beneath becomes inflamed, and the cartilage becomes 
eroded from beneath and loosened. Corresponding to these 
changes we have symptoms indicating the presence of inflam- 
mation of the bone. The previous mobility of the joint dimi- 
nishes, and is soon practically lost, partly on account of muscular 
rigidity, both voluntary to prevent pain, and involuntary from 
tonic contraction of the muscles, and partly on account of 
matting together of the walls of the synovial cavity. Accom- 
panying this rigidity there is, if no treatment has been adopted, 
gradually increasing flexion of the joint, ending in further 
deformity, to which I shall presently allude. There is now pain 
on attempting any movement, on pressing up the bones of the 
leg, and on pressing the patella backwards on to the femur, and 
there may be painful starting of the limb at night. The synovial 
thickening often increases somewhat at this stage, and the ends 
of the bones become enlarged. As the disease goes on, the 
ligaments of the joint become softened, so that the tibia can be 
moved laterally on the femur, and as the result of this soften- 
ing of the ligaments, the tibia becomes rotated outwards on the 
femur. Further, as the flexion goes on, the tibia becomes 
drawn up behind the femur, and the posterior part of the 
capsule shrinks, and thus the leg cannot be brought into a 
line with the thigh without considerable violence, and after 
division of the hamstrings or complete removal of the capsule 
by arthrectomy or removal of a portion of the bone. The 
typical final deformity of knee-joint disease is flexion of the 
leg to about a right angle, drawing up of the tibia behind the 



CARIES. 



255 



femur, and rotation outwards of the leg (see Fig. 43). At the 
same time the muscles of the thigh atrophy, but the leg, more 
especially, shows signs of wasting and, where the deformity has 
occurred early, and lasted some time, of deficient growth. On 
looking into the joint towards the end of this stage, it will be 
found that the articular cartilages have in places completely 
disappeared, leaving the inflamed and carious bone exposed, and 
in other places thinned and perforated shreds remain often 





Fig. 43. — Old standing disease of the knee joint, showing the 
typical deformity, viz. — flexion, drawing up of the tibia behind the 
femur, and rotation outwards of the leg. 

loosely attached to the subjacent bone. The fibro-cartilages 
have also been more or less destroyed. Further, destructive 
changes are noticeable in the bones, more especially in the 
head of the tibia, the external portion of which is often deeply 
excavated from pressure against the femur. 

3. As in the case of the hip-joint, we may place in a third 
group those cases where suppuration has occurred. Suppuration 



256 DISEASE OF THE KNEE JOINT. 

may occur early in the disease before the changes in the cartilages 
have gone on to any marked extent, or it may occur later where 
deformity has taken place. With the exception of the 
rare condition of empyema tuberculosum, described by Konig, 
abscesses occurring in the early stage of primary synovial dis- 
ease of the knee-joint do not, as a rule, in the first instance com- 
municate with the joint, but originate in the substance or the 
external portion of the affected synovial membrane. The most 
common seat of these abscesses is in front of the lower part of 
the femur, especially towards the inner side, beginning in con- 
nection with the synovial membrane of the supra-patellar pouch. 
When suppuration occurs during the second stage, it may either 
be in the form of caseous pus in the joint or abscesses around it 
and originating in the synovial membrane, but not necessarily 
communicating with the joint. Most usually when there are 
abscesses not communicating with the joint there is also a little 
pus inside, in fact, in most cases where one opens a joint at a 
late stage, one finds a little fluid with flaky material in it. In 
the case of these abscesses arising in connection with the 
synovial membrane, after being opened a communication may 
form with the joint, but this is not usually the case if treated 
aseptically. On the other hand, if the wound is septic the 
slight barrier between the abscess and the joint usually breaks 
down, and a probe can generally be passed through these 
sinuses directly into the joint. 

4. From the point of view of treatment, we may consider 
a fourth stage, in which the disease is evidently on the road 
to recovery, and where anchylosis, fibrous or bony, is taking 
place. Unless the disease comes to an end at an early stage 
there is always more or less complete stiffness, due not merely 
to cicatricial shrinking of the capsule with adhesions between 
adjacent portions, but also to actual union, either fibrous or 
osseous, between the bony surfaces. The earliest part to adhere 
is, as a rule, the patella with the surface of the femur. Whether 
fibrous or osseous anchylosis occurs depends on the degree to 



PRIMARY BONE DISEASE. 257 

which the articular cartilages are destroyed. Where the disease 
has ceased before they are completely destroyed at the opposed 
points the union will be fibrous; where, however, both bones 
are denuded, and the limb kept at rest, there will be osseous 
anchylosis. 

3. Primary Bone Disease. 

In the early stage, where the primary osseous deposits have 
not yet reached the surface, it is often most difficult to recog- 
nise them, indeed, where they are small and close to the 
surface, the first indication of disease may be when or just 
before they have formed a communication with the joint. 
Where they are larger, and situated in the substance of the 
epiphysis, they generally give rise, in the first instance, to a 
feeling of tiredness and aching, sometimes worse at night, and 
stiffness of the knee. On examination of the part, one finds 
some enlargement of the bone at the seat of disease, with a little 
tenderness on tapping, usually as time goes on becoming more 
marked at some one point. At this early stage, the synovial 
membrane is not thickened, and the area of bone affected can be 
easily made out. A good deal of information as to the exact 
seat of the disease may also be obtained by percussion. On 
percussion of healthy superficial spongy bone, a comparatively 
resonant note is obtained, but if the cancellous spaces are filled 
up at any one place with bone or caseating tissue, the note at that 
part is distinctly less resonant. The tapping must be pretty 
firm, and is, I believe, best done by means of a pleximeter. Of 
course, once the synovial membrane has become thickened, per- 
cussion does not yield a satisfactory result, for the bone must be 
quite superficial, otherwise the resonance is imperfect. 

As time goes on, the osseous deposit tends to make its way to 
the surface, and as I have already pointed out, it may reach the 
surface in three situations. Where it comes to the surface out- 
side the synovial capsule, the bone becomes more tender on 
pressure at that part, and at the most tender point the bone 

17 



258 DISEASE OF THE KNEE JOINT. 

softens, . and very soon an abscess appears, at the bottom of 
which, when opened, the defect in the bone is found. At first 
the movements of the joint may only be imperfect, and the 
patient may have pain on standing on it from the pressure on 
the inflamed bone, but the capsule remains without material 
thickening, and the cavity of the joint is sound. If the abscess 
is not properly dealt with, however, at an early period of the 
case, the synovial membrane of the joint is very apt to become 
thickened, and then the sequence of events formerly pointed out 
follows with the addition that an abscess exists from an early 
period outside the joint and that part of the bone is thickened 
and inflamed. 

In other cases the deposit reaches the surface at the point 
where the synovial membrane is reflected on to the bone, and it 
at once infects the synovial membrane. The result is that 
following the early symptoms which lead one to suspect that 
there is disease going on in the bone, thickening of the synovial 
membrane begins in the neighbourhood of the thickened bone, 
and rapidly spreads over the whole surface. The disease then 
follows the course of ordinary synovial disease, with the excep- 
tion that it is more stubborn, that it usually goes on more 
quickly, that there is more paiii and rigidity at an early period, 
and that abscess is very apt to form soon in the synovial mem- 
brane at the point where the osseous deposit has reached the 
surface. 

In the third form the osseous deposit reaches the surface 
beneath the articular cartilage, leads to destruction of the car- 
tilage over it, and then communicates with the joint. In this 
case the joint infection is usually preceded for a short time by 
more acute symptoms. The bone beneath the cartilage at the 
affected part becomes inflamed, and hence any movements which 
lead to pressure on that part cause pain, there is often a con- 
siderable amount of rigidity of the limb, and where the deposit 
is large, there may be starting of the limb at night, and this 
without thickening of the synovial membrane. The perforation 



SYMPTOMS OF BONE DEPOSITS. 259 

into the joint generally occurs pretty suddenly, and there is 
rapid increase in the symptoms. Not uncommonly the patient 
experiences sudden severe pain, probably at the time of perfora- 
tion, followed by swelling of the joint, and in some cases by 
fever, the whole joint becomes rapidly affected, the surface of 
the synovial membrane undergoes caseation, and the cartilage is 
quickly destroyed. In fact, the condition is that described in the 
older text-books as acute ulceration of cartilages. In this con- 
dition some cheesy pus is generally formed at an early period in 
the joint, the patient suffers much pain, especially on the slightest 
movement, there is starting pain at night, the knee is rigid and 
flexed, the ends of the bones are enlarged, but in the first 
instance the ligaments are not softened, and lateral mobility is 
not present. When abscesses form and are opened, they are 
found to communicate with the joint, and the probe passes 
into the soft carious and very sensitive bone. If recovery takes 
place after this condition there is bony anchylosis. 

Cases of the kind just referred to where the onset of the 
acute symptoms is sudden and probably coincident with the 
formation of a communication between a deposit in the bones 
and the cavity of the joint, are not so uncommon as one might 
at first sight suppose, and I have notes of several instances. 
For example, a female, cet. 25, was the subject of chronic 
phthisis, and for two winters had suffered from occasional pain 
in the knee. One night she woke with sudden violent pain in 
the knee, which soon became swollen and extremely painful, 
and rapidly acquired the appearance of typical tubercular 
disease with pus in the joint. In this case the tubercular 
nature of the disease was confirmed on microscopical exam- 
ination, and a primary deposit was found in the head of the 
tibia which communicated with the joint. The previous 
uneasiness in the joint was, no doubt, due to the presence of 
this deposit, and the development of the acute symptoms 
coincided with the formation of a communication between the 
deposit and the joint cavity. I could mention other similar 



260 DISEASE OF THE KNEE JOINT. 

cases not only in connection with the knee-joint but in other 
joints, and while some of them might he referred to the sudden 
deposit of a tubercular embolus in some of the structures of the 
joint, the majority are dependent on the rupture of a deposit 
into the articular cavity. 

Diagnosis of Tubercular Disease of the Knee Joint. 

Acute synovitis. — The only cases in which acute synovitis and 
tubercular disease of the knee-joint are difficult to distinguish 
are either where the tubercular disease begins acutely or where 
an osseous deposit has burst into the joint. In some cases 
tubercular disease begins quite acutely and, in the first 
instance, presents the appearance of an ordinary acute synovitis, 
and cannot be distinguished from it especially where it follows 
on an injury. In such a case the suspicion of tuberculosis may 
not be aroused till it is found that, in spite of thorough treat- 
ment, the joint remains swollen and the synovial membrane 
becomes thickened, or that suppuration is occurring without 
any of the acute symptoms characteristic of suppuration 
due to the ordinary pyogenic organisms. I speak of such 
cases as this, where a boy fell and hurt his knee; this was 
followed by acute synovitis which soon lost its acute character 
but left the knee swollen, and a chronic abscess shortly after- 
wards developed ; this child subsequently died of tubercular 
meningitis. In other cases the acuteness of the symptoms is 
preceded for some time by discomfort or actual aching in the 
knee and perhaps by some enlargement of the bones. Such 
was the case referred to in the the last paragraph; in these 
instances there is not usually much difficulty in the 
diagnosis. 

Hydrops articuli. — Here also there is not, as a rule, much 
difficulty in diagnosis ; in the one case the joint is full of fluid 
and the synovial membrane is not thickened ; in the other the 
essential part of the swelling is due to thickening of the synovial 



DIAGNOSIS. 261 

membrane. The cases which are difficult to diagnose are those 
where the tubercular disease begins with a hydrops of the joint 
or with the development of pus in it without much thickening 
of the synovial membrane in the first instance; Volkmann's 
hydrops tuberculosus and empyema tuberculosum. These cases 
are rare but they do occur and the possibility should be borne 
in mind. Here the disease begins with distension of the joint 
with fluid, but as time goes on the synovial membrane 
becomes thickened and the diagnosis becomes evident ; where, 
on aspiration, curdy pus is drawn off the diagnosis is, of course, 
made at once. Suspicion would also be aroused in cases where 
there was tubercular disease elsewhere, and where the swelling 
of the joint occurred without any evident cause. 

Loose cartilage. — The cases where the question of loose 
cartilage would arise are those where pedunculated tubercular 
tumours are attached to the synovial membrane, cases to which 
I have already referred. In these instances, however, the swelling 
is usually much larger than the typical loose cartilage, at any 
rate a simple loose cartilage which had attained that size would 
have become detached. The difficulty in these cases is not so 
much to distinguish them from cases of loose cartilage as from 
tumours, fatty or otherwise, outside the joint. These tubercular 
tumours are, however, generally associated with effusion into the 
joint, and they can usually be moved in such a way as to show 
that they are hanging, free in the joint cavity. A difficulty 
may arise where there are numerous rice bodies in the joint, as 
I have seen in other joints, which may be mistaken for 
simple loose cartilage, but their number, and the fact that on 
cutting into them they are seen to be composed of fibrin and 
not of the ordinary structure of loose cartilage, shows the 
difference. Further, in these cases the synovial membrane is 
usually thickened, fleshy, and coarsely villous. 

Bheumatoid arthritis. — This difficulty arises chiefly in older 
patients, and it is not always easy on first seeing the case to be 
quite certain whether one has to do with an early rheumatoid 



262 DISEASE OF THE KNEE JOINT. 

arthritis or an early tubercular disease ; of course in the later 
stages there is no difficulty. In rheumatoid arthritis the joint 
is usually sensitive to wet and cold, and is subject to attacks of 
pain and tenderness, which subside ; creaking can be felt in the 
joint ; the synovial membrane is not markedly thickened, and 
very often enlarged villi can be felt rolling under one's finger over 
the bone ; there is early enlargement and deformity of the bones, 
and great tendency to stiffness. Very often the disease is poly- 
articular. 

Charcot's disease is so well known and its features so 
characteristic that it need not be considered here. Hysteria 
in the knee, as elsewhere, is characterised by the absence of 
local signs, the exaggeration of pain, and other symptoms. 

Syphilitic joint diseases are not likely to be confounded. 
The synovitis which occurs in secondary syphilis is transient, 
is intimately associated with other lesions, and in no way 
resembles tubercular disease. Gummatous disease might per- 
haps lead to difficulty. As a rule, gummata form in the 
subcutaneous tissue, and lead to the characteristic ulceration of 
the skin which can hardly be mistaken. Where they are formed 
deeper, there is not generally diffuse thickening of the synovial 
membrane but the presence of isolated nodules softening in the 
centre, and the other symptoms of knee-joint disease are absent. 
The matter is sometimes complicated, however, where there 
have been periosteal gummata which have broken through the 
skin and also formed a communication with the joint, and where 
the probe passes down to bare bone. This condition, however, is, 
I believe, rarer than has been supposed, and most of the cases 
which have been taken for it have in reality been cases of 
tubercular disease. Diffuse gummatous infiltration of the sub- 
synovial tissue is excessively rare. The possibility that the 
thickening may be tumour growth must also be borne in mind, 
and I have seen a tumour of the lower end of the femur which 
had burst into the joint opened on the impression that it was a 
case of tubercular joint disease. In tumours in the interior of 



TREATMENT. 263 

the bone, the swelling of the bone is usually more general than 
in the case of a tubercular deposit, and extends beyond the 
region of the joint. Care must also be taken to distinguish an 
acute epiphysitis in children with effusion into the joint from 
tubercular disease. This is not so likely to cause difficulty during 
the acute stage as afterwards, where one may have to depend on 
an imperfect history. 

Treatment of Knee Joint Disease. 

The treatment of knee-joint disease varies according to the 
pathological condition and the stage of the disease. In the first 
class of cases, where we have the localised synovial disease either 
sessile or pedunculated, the proper practice clearly is, in view of 
the safety with which joints can now be opened aseptically, to 
cut down and remove the whole affected area as soon as possible. 
This was done in the case to which I have referred, with the 
result that there was perfect recovery, with a freely movable 
joint. I have in one or two instances, also obtained similar 
results in localised synovial deposits in other joints, and in 
Germany Konig and others have in several cases removed these 
pedunculated tumours successfully. They state, however, that 
in a certain number of the cases gradual thickening of the 
synovial membrane has subsequently occiirred. 

The treatment of the general synovial thickening varies, of 
course, according to the condition of the joint, the means we 
have at our disposal being the various forms of expectant treat- 
ment, partial or complete arthrectomy, treatment of abscesses 
alone, excision and amputation. "We must consider shortly the 
circumstances under which these various forms of treatment are 
applicable. I may at once say that the knee-joint being a much 
more accessible joint than the hip, it is not now considered 
advisable to continue expectant treatment for so long a time, 
because much can be done to shorten the disease and get a good 
functional result by comparatively early operation. 



264 DISEASE OF THE KNEE JOINT. 

1, In the early stage of synovial disease, where the thicken- 
ing is not great, and where there is absence of pain, and no 
marked interference with movement the essential part of the 
treatment is complete fixation of the joint. There are a number 
of methods by which this may be accomplished, but whichever 
be employed, it is in my opinion advisable that in the first 
instance the patient should be kept in bed and in the recumbent 
posture. I advise the recumbent position, because every time 
the patient sits up he contracts the extensor cruris, and thus 
pulls up the patella. Hence it is well, while the disease is pro- 
gressing, and while very little may interfere with the commence- 
ment of recovery to prevent the patient from sitting up by 
means of heavy sand bags applied along each side of the body 
with a sheet passing over the chest. At the same time, the 
ankle should also be supported and fixed at right angles. 
Patients constantly complain of uneasiness and pain if this is not 
done, and the muscles of the calf are apt to become contracted 
and lead to subsequent difficulty in getting the foot flat on the 
ground. In the first instance, I think it is advisable to employ 
an apparatus which can be readily opened without disturbing 
the joint, so as to enable the surgeon to see from time to time 
what is going on. The various forms of rigid apparatus, how- 
ever useful, are for this reason best limited to later stages, when 
it is evident that the disease has come to a standstill or is im- 
proving, but if desired, they can be used at this stage by cutting 
them down the front, and then using laces. 

Of the various forms of splints, I prefer a trough of Gooch's 
splint during the early stage. The splint should reach from the 
fold of the buttock above to about 4 inches beyond the sole of 
the foot, and should surround the thigh and knee for about 
two-thirds of their circumference. It is cut obliquely at its 
upper end upwards and outwards to correspond with the fold of 
the buttock, and in the case of adults, a horse-shoe space should 
be cut away at the lower part, so as to avoid pressure on the 
heel ; in this way, two prongs are left, which grasp the instep 



SPLINT FOR KNEE JOINT DISEASE. 265 

and steady the ankle. In young children, however, where the 
splint is short, this weakens it, and the heel can easily he kept 
from pressure by pads. The splint is covered with a layer of 
jaconet, and then with a folded sheet turned over the upper end, 
and at the lower part folded up just above the horse-shoe defect. 
A layer of cotton wool is placed in the ham, so as to give sup- 
port to the knee, and prevent over extension, and the leg above 
the heel is properly supported on wool or pads, so as to prevent 
the heel from touching the splint. The splint being then turned 
up, and pressed against the limb, pads are pushed in all along 
the side, so as to wedge the leg and thigh, and also prevent 
pressure on bony points, more especially the internal condyle of 
the femur and the malleoli. To avoid the latter, the pads do 
not reach further than the base of the malleoli, and in order to 
fix the foot a number of pads are placed between the prongs of 
the splint and the sides of the foot ; the knee and the front of 
the leg are now covered with pads, so that the bandage, in pass- 
ing round may get a purchase on the limb. A bandage is now 
firmly applied, and then at the upper part a layer of Mackintosh 
is pinned along the inner side of the splint to prevent wetting 
of the bandage with urine. The limb is then placed on an 
inclined plane. In some cases it is well to apply a layer of 
starch to the bandage to prevent it from slipping. The bandage 
should be renewed whenever it gets loose, generally about once 
a week. This form of splint is, I believe, much better than a 
plain flat back splint, or than Thomas's knee splint. A plain 
back splint gives no lateral support either to limb or ankle, 
and the mode in which it is commonly fixed by strips of 
strapping above and below beneath the bandage is most 
objectionable, because it leads to constriction of the circula- 
tion. 

After six or eight weeks, if the thickening is diminishing, or 
at any rate not increasing, it is best to apply a water-glass or 
plaster of Paris bandage, preferably the former. A bandage of 
boracic lint is first put on, the knee is wrapped in a thick 



266 DISEASE OF THE KNEE JOINT. 

layer of wool, and then the silicate bandages applied firmly, 
especially around the knee. This bandage should include the 
foot, and extend as high up the thigh as possible. One must 
be careful to carry the case as high up the thigh as possible, 
for unless this is done, movement will occur at the knee. 
I think it is well not to trust altogether to the water- 
glass bandage, but to combine with it Thomas's knee splint. 
Thomas's splint alone does not, I think, give sufficient support ; 
it gives practically no lateral support, and I believe this is most 
essential in order to prevent strain on the ligaments of the 
joint. On the other hand, it is difficult to get a proper grasp 
of the thigh with the silicate bandage, while this is done by 
Thomas's splint. Hence, I believe, the combination is a most 
satisfactory arrangement, and that it is by far the best method 
of using Thomas's splint. 

Thomas's knee splint consists of a groin ring, lateral rods 
running down the inner and outer sides of the limb, attached 
at the bottom to a boot, and three broad leather bands behind 
to support the limb. The groin ring is of an ovoid shape, the 
narrowest part being at the outer side, the inner part, which 
rests on the tuber ischii, being thickly padded. This ring lies 
obliquely in the fold of the groin, the inner rod being attached to 
it at an angle of 120°, the angle on the outer side varying with 
the shape of the limb. In the case of the bed splint the lateral 
rods are attached at the longest diameters of the ovoid ; in the 
walking splint the inner rod is attached further back. At the 
lower end the foot is inclosed in a boot, which is cut away in a 
V-shaped manner at the back part, and the lateral rods are bent 
at right angles, and passed into holes in the heel. The posterior 
leather bands are three in number, one about the middle of the 
thigh, one behind the knee, and one behind the lower part of the 
leg. The splint is fixed to the leg by two broad straps passing 
in front, one above and one below the knee. If flexion is pre- 
sent, these straps are employed to overcome it. If there is a 
tendency to knock-knee, the thigh is pulled outwards by a band 



THOMAS'S KNEE SPLINT. 267 

attached to the outer rod, while the inner rod is bent inwards, 
so as not to press on the inner condyle. 

A very important question is whether the patient should be 
kept in bed, or whether he should be allowed to get about with 
crutches. My own opinion is that so long as the disease is at 
all active, the recumbent posture, not necessarily in bed, should 
be rigidly maintained. We have constant experience that 
ulcers on the leg will not heal, or only with great difficulty, so 
long as the patient walks about or hangs down the leg, while 
they begin to heal at once on placing the patient in bed. Even 
in young people, we see that wounds in the leg are long in 
healing while the patients run about, and may even ulcerate. 
The same must apply to a deep-seated inflammatory trouble, and 
I believe, therefore, that the recumbent posture should be kept 
up in knee disease till the part is well advanced on the way to 
recovery. The chief objection urged against this course is that 
the patient does not get enough exercise, and is too much con- 
fined to the house, but these objections can be readily overcome. 
The patient can be wheeled out in the recumbent posture, and if 
a warm country place is selected, he can lie out the greater part 
of the day. As regards exercise general massage is an excellent 
substitute, and by its use the patient's nutrition can be main- 
tained at a high level. "When the patient is allowed to get 
about, Thomas's walking knee-splint, slung from the shoulder by 
a strap, is by far the best apparatus. By means of it no pressure 
is brought to bear on the joint, the lateral rods are continued 
down to a foot-piece below the boot, and thus the weight of the 
body is borne on the tuber ischii against which the upper ring 
rests. The other foot is raised to the same level, and the patient 
gets about with crutches. The plan of putting the leg up in 
waterglass, and allowing the patient to walk about is bad, 
because there is constant pressure on the joint, and this method 
should not be adopted unless in very exceptional circumstances, 
and then only when the disease is purely synovial, and well on 
the road to cure. 



268 DISEASE OF THE KNEE JOINT. 

Additional means of treatment which, however, I do not 
think of much value in knee-joint disease, are pressure and 
counter irritation. Pressure is a very old method of treating all 
chronic inflammatory affections, and if carefully and judiciously 
applied it certainly does good, but if too strong and irregular it 
causes a great deal of harm. The essential points in the applica- 
tion of pressure are, therefore, that it should be equable and 
moderate. Perhaps the best way in which this can be done is 
by surrounding the joint by a large mass of cotton wool or silk 
waste, and then applying a bandage firmly. The mass of wool 
distributes the pressure equally over the part, and what at first 
sight seemed likely to be a very bulky mass, becomes reduced 
under an evenly and firmly applied bandage to a comparatively 
small size. The limb is then placed on a splint, care being 
taken to pad the thigh and leg so as to correspond with the 
bulk of the knee. Another favourite way in which pressure is 
applied is by means of Scott's dressing, and here also there is a 
certain amount of counter irritation as well. I must say that 
I do not see any advantage in Scott's dressing, over pressure by 
means of a mass of cotton wool ; indeed, the pressure is not so 
firm and equable. 

As to counter irritation in the early stage of synovial disease 
of the knee-joint, it is very much the fashion to apply strong 
iodine and blisters at this stage. My own opinion is that this 
is not good practice. The synovial membrane of the knee is 
very superficial, and blisters applied to the skin may increase 
the congestion, and thus rather favour the inflammatory action 
than otherwise. It is different where the disease is improving, 
there the application of a few blisters may hasten matters, but 
on the whole, great care must be exercised in using counter 
irritation at any stage. 

As regards extension, from what I said in speaking of hip- 
joint disease, it will be evident that extension will not come 
into play in the treatment of the earlier stages of synovial 
disease, and it need not therefore be considered here. If there 



EARLY OPERATION. 269 

is any flexion at this stage that is easily overcome without 
any necessity for extension, by gentle pressure without any 
violence. 

In the early stage of hip-joint disease, as I pointed out, we 
had not to consider the question of operation except in those 
cases where it was probable that a deposit was present in the 
neck of the femur, which had not yet opened into the joint, but 
in the case of the knee the matter is different, and in certain 
cases of pure synovial disease great advantage may be obtained 
by operation at an early stage before the articular cartilages 
have been destroyed. These operations consist of arthrotomy 
and partial or complete arthrectomy in children, arthrotomy 
and excision in adults. In a certain number of cases the 
swelling does not subside under rest, but either remains 
stationary or increases ; the swelling in these cases is usually 
soft and gelatinous, hence the name " gelatinous degeneration 
of the synovial membrane," and abscesses are very apt to form 
at an early period. In such instances the cartilage will soon 
become affected, and the surface of the bone carious, and it is 
in certain cases wise to make an effort to cut short the 
disease by operation before this has taken place, so as to get 
a certain amount of restoration of function. In the case of 
children, at any rate, I should not waste time with arthrotomy, 
but at once employ partial or complete arthrectomy. It must, 
of course, be remembered that complete arthrectomy of the 
knee-joint is an operation by no means devoid of danger (shock), 
and therefore not to be lightly undertaken, but where a case is 
advancing in spite of proper rest, and especially where there is 
evidence of breaking down, this question of arthrectomy should 
always be considered before there are signs of destruction of 
cartilage. The objection raised by practitioners to the question 
of operation at this early period is that these cases often ulti- 
mately get well without operation by prolonged treatment by 
fixation, frequent trips to the country, &c. This is no doubt 
true, but a considerable number of the class of cases of which 



270 DISEASE OF THE KNEE JOINT. 

I am speaking do not get well in this manner, abscesses form 
and burst or are opened, and septic sinuses are left, the patient 
becomes worn out by pain and discharge from these sinuses, 
disease of the lungs sets in, and a time comes when the question 
lies between amputation and leaving the patient to die. Further; 
iu cases in which the disease advances in this way, if recovery 
does take place, the joint is anchylosed, and years are passed 
as an invalid, during which time the education of the child is 
neglected, and the confinement tells on his general physique. 
On the other hand, where arthrectomy is successful, the disease 
is brought to an end at once, the patient is able to get about in 
a comparatively short time, and in a considerable number of 
the cases a certain amount of movement (sometimes marked) is 
ultimately obtained. I think, therefore, that, as I have already 
said, this question should always be considered comparatively 
early in those cases where the disease is steadily advancing, 
where the thickened synovial membrane is soft, and where 
there is a tendency to abscess formation. In coming to a 
decision, the risk of the operation (shock) and the general 
state of the patient must be thoroughly weighed. In these 
rapidly advancing cases in children, arthrectomy, if done at 
all, must be complete, and I shall now describe the best way of 
doing it in the case of the knee. 

t Numerous incisions are recommended, but the method which 
seems to me best is, in the first instance, to make a long verti- 
tical incision on each side of the patella. These incisions run 
from a \ to 1 inch from the border of the patella, according to 
the size of the part and the degree of the synovial thickening, 
commencing above at the level of the upper part of the supra- 
patellar pouch, and ending about an inch below the level of the 
upper surface of the head of the tibia. These incisions are 
deepened throughout their whole extent till the outer surface 
of the capsule is exposed, and the flaps are then lifted to each 
side, care being taken not to cut into the tubercular tissue, till 
the whole of the synovial membrane in front of the joint is 



ARTHRECTOMY. 271 

exposed. The suprapatellar pouch of synovial membrane is 
then freed, where it overhangs the front and sides of the femur, 
up to the point of attachment to the articular cartilages, the 
ligamentum patellae being also raised, and freed from the fatty 
pads and the tissues beneath. The synovial membrane is then 
cut away all round the patella, and if fluid is present in the 
joint, it is sponged or washed out. The membrane is then de- 
tached at the point of attachment to the articular cartilages of 
the femur and the tibia, and divided as far back at each side as 
possible. In a certain number of eases I have done the whole 
operation by means of these two incisions, dislocating the patella 
over one or other condyle in turn ; but this sometimes causes 
a good deal of bruising of the edges of the wound, and, there- 
fore, I now usually make a transverse incision over the middle 
of the patella, saw through the bone, and turn the flaps up 
and down. The objection I at first had to that was the fear 
lest the cut surface of the bone should become infected, but 
this has not happened in my cases. The joint is now bent, and 
the soft tissue covering the crucial ligaments and in the con- 
dyloid notch cleaned away as thoroughly as possible; this is 
one of the most difficult things to do. The crucial ligaments 
are then divided about the middle, and also the lateral liga- 
ments, and the thickened synovial membrane is sought for 
at each side, and its outer surface defined. This outer surface 
is separated from the vessels and structures in the popliteal 
space as high as its attachment to the femur above and the 
tibia below, and is then cut away at those parts. In detaching 
the posterior part of the capsule, it is well, if a tourniquet has 
been employed, to remove it, in order that one may have the 
pulsations of the popliteal artery as a guide. The inter-articular 
fibro-cartilages are then removed, and the whole of the edge of 
the articular cartilage carefully gone over, to make sure that 
no pieces of diseased synovial membrane have been left attached. 
The whole surface of the cartilage is now carefully inspected, 
and if there is any sign of pitting or disease anywhere, the 



272 DISEASE OF THE KNEE JOINT. 

affected piece is scooped out, "What one very commonly finds, 
without any definite destruction of cartilage, is that the surface 
of the cartilage is covered with a dull velvety layer, which is 
not readily detached. This must be removed as far as possible, 
and that I do either by scrubbing it thoroughly with a nail- 
brush, or, where still more adherent, by scraping it away with 
a knife. Having thoroughly satisfied one's self that the disease 
has been removed, catgut stitches are put in the crucial and 
lateral ligaments, the patella drilled and wired together, the 
wounds stitched up — if one likes, after filling the joint with 
iodoform and glycerine, but I do not think that is necessary — 
antiseptic dressings applied, and the limb placed on a back 
splint. If the operation has been done aseptically, it will not 
usually be necessary to touch the dressing before from four to 
six weeks, when the wound will be found healed, and the 
stitches may be taken out. I think it is well to prevent the 
patient from walking for about three months after the opera- 
tion, and subsequently a Thomas's knee splint must be worn, to 
prevent flexion of the joint. This splint must be altered from 
time to time, and may, after a time, be changed for a poroplastic 
splint lacing in front. Some form of retentive apparatus should 
be continued for two or three years, or, if left off sooner, with 
the view of allowing movement, resumed at once on any appear- 
ance of flexion. In performing the operation, it is a question 
whether a tourniquet should be used or not. It is no doubt 
easier to distinguish the diseased and healthy tissues while the 
blood is circulating through them, and the after bleeding is less, 
but where the child is weakly, perhaps less blood, on the whole, 
is lost where a tourniquet is used. If it is employed, it is well, 
as I have already said, to remove it before the dissection of the 
posterior part of the synovial capsule is proceeded with, in order 
to have the pulsations of the popliteal artery as a guide. 

While in these rapidly spreading cases my experience is that 
complete arthrectomy is the proper procedure, yet in a certain 
number of cases a partial operation will yield a good result. 



ARTHRECTOMY. 273 

Cases, for instance, which do not improve with rest, but where 
the progress of the disease is slow, and the thickening of the 
synovial membrane not very great. These are the cases which 
are improved by simple arthrotomy, but, as I have already 
said, I believe that, if one is to cut into the joint, it is well 
to remove as much of the disease as possible. In cases of 
this kind, therefore, I dissect away the whole of the anterior 
synovial membrane, but do not divide the crucial or lateral 
ligaments, and thus the joint remains firm, and I have had 
some excellent recoveries with movable joints after this pro- 
cedure. In some cases, however, I have been disappointed in 
the result, and the course I adopt now is to be guided not so 
much by the external appearance of the joint as by the char- 
acter of the synovial membrane when it is cut into. If it is 
firm and uniform in appearance, without signs of caseation, and 
if the cartilages are intact, then I sometimes content myself 
with a partial arthrectomy; but if the synovial membrane is 
speckled with yellow points, or if the cartilages are becoming 
affected, then I do a complete arthrectomy. 

In the case of adults I would not advocate such early in- 
terference, because the results of arthrectomy of the knee-joint 
are not so favourable in them. It is but rarely that one can 
get a useful movable limb, usually there is more or less complete 
stiffness of the knee, but never the perfect rigidity obtained by 
excision. Hence, the knee is apt to give, and the adhesions 
being stretched become tender, and the patient does not walk 
comfortably. I believe that in adults excision will yield a 
better result on the whole, and, therefore, unless where there is 
some special reason for getting a rapid cure, I should not, as a 
rule, consider the question of operation in adults till during the 
second stage. 

Another method of treatment during the early stage of joint 
disease, especially in the case of the knee, is now much employed 
in Germany, viz., the injection of iodoform emulsion into the 
joint. I cannot say, however, that I think very highly of this plan. 

18 



274 DISEASE OF THE KNEE JOINT. 

2. In the later stage of primary synovial disease, where the 
cartilage has become affected and the surface of the bone 
carious, the relative frequency of operation in the old and young 
becomes altered. In the first stage operation is more frequent 
in the young than in the old ; in this stage I think operation 
should be more frequent in the old than in the young. While, 
so long as the cartilages are unaffected or but slightly attacked, 
a cure of the disease and a good functional result may be looked 
for from early operation in children, the conditions are not the 
same where the cartilages are destroyed, and the surfaces of the 
bones carious. In that case, in order to get rid of the disease 
by arthrectomy, portions of bone have to be removed, a large 
surface of soft bone is left, which is very apt to become infected 
again, and even where the epiphysial cartilages are not touched, 
ossification is apt to occur in them, with consequent arrest of 
growth. Hence, in children where the stage of destruction of 
cartilage and caries has become established, I think it is wisest 
to persevere as long as possible with expectant treatment, and 
only to operate when it is evident that no improvement is 
going to take place, when there is much flexion which cannot be 
overcome by splints, when the general health of the patient is 
suffering, and especially when the third stage, that of abscess 
formation, has set in. While carrying on the expectant treat- 
ment, it might be worth while to use the iodoform and glycerine 
injections, and in some cases, where there is much starting, 
extension carried out, as in the hip, will be of value. As 
regards operations during this stage in children, arthrectomy 
is still the proper procedure, excision in which the epiphysial 
cartilages are almost unavoidably injured being in my opinion 
very rarely, if ever, justifiable in children. Some have advised 
an intra-epiphysial excision, the lines of division of the bone 
being so arranged as to fall inside the epiphysial lines, but even 
after this operation the condensation of the bone which accom- 
panies the healing process is very apt to extend to the cartilages 
and lead to their ossification, and consequently to arrest of growth. 



ARTHRECTOMY AT A LATER STAGE. 275 

Where operation becomes necessary, it should be an arthrectomy, 
viz. — complete removal of the synovial membrane in the manner 
formerly described, and removal of all affected bone with as 
little of the sound bone as possible. This means that there is 
no sawing off of the ends of the bones, the removal of bone 
being quite irregular ; as a rule, the original shape of the end of 
the bone is more or less preserved. In removing the carious 
-surface, it is important to remember what has been previously 
pointed out, that the tubercular disease in the case of caries of 
the surface does not extend more than \ to \ inch into the 
substance of the bone, so that it is not necessary to take away 
more. The best way of proceeding is, after the synovial mem- 
brane has been thoroughly removed, and the joint thoroughly 
cleared out, so as to diminish the risk of infection, to take a 
strong knife and shave off about \ inch of the whole surface of 
the bone. Even though cartilage be still adherent in parts, it 
is, I believe, best to take it away with a thin piece of the 
underlying bone. Care is taken as far as possible not to infect 
the cut surface while dealing with other parts of the bone. One 
must remember that congested bone is not necessarily infected 
bone, otherwise one would remove far too much, and also that 
the rarefying osteitis is not uniform, but tends to be in patches. 
The ultimate result of this operation in the knee-joint, where 
the cartilages of both femur and tibia are affected and removed 
is, in most cases, bony anchylosis, and the only objection which 
can be raised in favour of a typical intra-epiphysial excision 
over an atypical arthrectomy, is that in the former the surfaces 
of the bone are broader and fit better than in the latter. No 
doubt this is true, but as a matter of fact the union after 
arthrectomy is quite good, and the risk of interference with 
growth is decidedly less. 

In the case of adults the best result to be hoped for by 
expectant treatment is bony anchylosis, and this means devoting 
a long time to treatment, running the risk of general disease 
and of local suppuration, with all its troubles, and even where 



276 DISEASE OF THE KNEE JOINT. 

apparent recovery takes place, portions of tubercular tissue are 
very apt to have become encapsuled, and give rise to fresh trouble 
at a later period. By excision the progress of the disease is cut 
short, the patient gets well quickly, and has a sound and useful 
limb, while, as he has attained his full growth, the shortening 
is not practically appreciable. The only objection to operation 
in this stage is that there is a certain risk of shock in feeble 
individuals, but if the cases are selected from this point of view, 
excision as now performed is a much more satisfactory method 
of treatment than long continued perseverance in expectant 
measures. The former objection to excision was founded partly 
on the septic dangers, which were very considerable, and partly 
on the frequency of recurrence. Now-a-days, with unbroken 
skin the risk of sepsis after operation may be disregarded, while, 
by the present method of operating, the diseased tissues are 
completely taken away, and in the case of primary synovial 
disease which we are discussing at present, the chance of 
recurrence is very slight. The following is, in my opinion, the 
best method of performing excision of the knee-joint : — 

An incision is made from the upper and back part of one 
condyle downwards, and then, curving round the front of the 
upper part of the tibia, at the level of the tuberosity, it passes 
up again to a corresponding point on the other side. If the 
knee is movable this is best done with the leg bent at a right 
angle. From the same points a second curved incision is made, 
passing over the upper part of the ligamentum patella, and in this 
way a crescent-shaped portion of skin is enclosed and removed, 
otherwise the front flap is redundant, and has to be cut down 
subsequently. The flap consisting of skin, fat, and fascia, at the 
lower part, and of muscle as well at the upper part, is then 
raised, the patella being left, and care being taken not to cut 
into the synovial membrane till the supra-patellar pouch has 
been completely passed. The flap is then held up, and the 
supra-patellar pouch is grasped and pulled down, till the point 
of reflection on to the cartilage of the femur is seen ; it is then 



EXCISION. 277 

detached along that line, and, following the lower incision, at 
the sides and lower part of the joint. In this way the whole of 
the anterior synovial membrane, the patella, ligamentum patella?, 
and fatty pads, are removed. I think, however, that it is well 
to leave a portion of the ligamentum patella? to be subsequently 
stitched to the divided parts of the quadriceps. The knee is 
now forcibly bent, the crucial ligaments divided at their tibial 
attachments, the ends of the bones cleared and sawn off in 
the usual manner. All other portions of carious bone, or of 
cartilage-covered bone, are sawn or chiselled off, and then the 
remainder of the synovial membrane is removed in the manner 
described under arthrectomy. Having made sure that all the 
diseased tissues have been removed, the bleeding points are 
secured, the cavity washed out, and the bones pegged together 
by ivory pegs. I usually put in two, one on each side, driving 
them upwards and backwards. In approximating the cut ends 
of the bone it is of great importance to remember that the cut 
surface of the tibia is broader than that of the femur, and that 
if the anterior edges are brought level, the posterior part of the 
upper end of the tibia will project back into the ham, and press 
on the vessels, causing, in some cases gangrene, in others imper- 
fect circulation in the lower extremity and consequent deficient 
nutrition and growth. The posterior edges must, therefore, be 
brought level, and the anterior part of the tibia allowed to pro- 
ject forward, and hence it is easier to drive the pegs upwards 
from the tibia than downwards from the femur. In some cases 
I have used a third peg in the centre, and thus got great steadi- 
ness. Having fixed the bones, it is well to stitch the divided 
extensor to the remains of the ligamentum patellae ; or, if that 
has been taken away, to the periosteum of the tibia, so as to get 
better leverage on the limb afterwards. The skin is then 
stitched up, a drainage tube being rarely required, the usual 
antiseptic dressings in large quantity applied, and the limb 
securely fixed in a trough of Gooch's splint, which is laid on a 
wooden inclined plane. I do not usually dress these cases for 



278 DISEASE OF THE KNEE JOINT. 

from four to six weeks, when it is found that bony union is 
pretty firm, and a case of silicate or plaster can be applied for 
another six weeks. No harm is done by leaving the stitches, 
there is no tension on them, and they cause no irritation if the 
aseptic measures have been properly carried out, while the blood 
which oozes into the dressing during the first twenty-four hours 
dries up into a hard crust, so that in a few days the neighbour- 
hood of the knee is surrounded by a hard dry mass, which 
grasps it most firmly, more so than a plaster of Paris case, and 
thus very complete steadiness is obtained. From time to time 
during the first six weeks a fresh external bandage may be 
firmly applied if the other tends to get loose, and special care 
must be taken to keep the foot at right angles by a turn of 
bandage passed round the sole, and pinned to the bandage in 
front of the leg. 

The question of amputation during this stage may also arise, 
but it will hardly concern the young. Some years ago, and 
even by a good many surgeons at the present time, it was held 
that after forty years of age excision was impracticable on 
account of the immediate risk to life, of the great chance of 
recurrence, and of the bad effects of confinement to bed. As 
a matter of fact the answer to the question has now changed, 
and these are not the chief reasons which make one prefer 
amputation to excision in certain cases. Thus the risk to life 
formerly spoken of was the risk of septic disease, but as there 
are no sinuses in the cases we are discussing at present, this 
risk is with proper precautions extremely slight. The chance 
of recurrence was of course great formerly where the whole 
disease was never removed ; certain incisions were made, certain 
portions of bone were cut off, but no attempt was made to 
remove the whole of the synovial membrane, hence the disease 
went on in the soft parts often for a long time, sinuses remained 
or fresh abscesses formed, and portions of the freshly-cut osseous 
surfaces became infected and carious. With the present method 
of operating the greatest care is taken to remove all the diseased 



TREATMENT OF THE THIRD STAGE. 279 

tissues, and the chance of recurrence after operation is very 
much less. As regards the confinement to bed, no doubt a 
patient can get up much sooner after amputation than after 
excision, but if the bones are well pegged and the limb firmly 
fixed, he can usually sit up in two or three weeks after excision. 
This is no doubt a very important point, and the general con- 
dition of the patient, and the risk of confining him to bed for 
some weeks, must be carefully considered in deciding between 
the two operations. 

For the above reasons, therefore, I would not necessarily 
exclude older people from the benefits of excision, for it must be 
remembered that a limb after excision is very much better than 
an artificial one, however well made, and at this stage of the 
disease, I think even after forty years of age, excision is as a 
rule to be preferred to amputation. Amputation, however, is 
the best practice where the patient is suffering from tuberculosis 
elsewhere, especially in the lungs, or where the synovial thicken- 
ing is great and soft, and much starting pain is present, 
indicating considerable inflammation of the bone. When 
amputation is performed, I do not approve of such operations 
as Carden's, where the incision passes through diseased tissue. 
I think the bone should be divided through the lower third of 
the femur, the soft parts being dissected up without opening the 
joint, and the synovial capsule pulled down out of the way. 

3. The third stage of primary synovial disease is that where 
suppuration has taken place, and where we have either un- 
opened abscesses or sinuses. 

(a) Unopened Abscesses.- — Here, again, we must speak of 
children and adults separately. 

In children it will depend very much on the condition of the 
joint as a whole what form the operative interference should 
take. Where there is a single abscess, and the condition of the 
joint is not otherwise bad, it is often sufficient to deal with the 
abscess alone, and afterwards employ suitable expectant treat- 
ment. Under such circumstances an attempt should in most 



280 DISEASE OF THE KNEE JOINT. 

cases be made to dissect the abscess out altogether without 
opening the joint, or if the abscess is extensive, it may be washed 
and scraped out and injected with iodoform and glycerine. 
Where there is more than one abscess, or where the condition 
of the joint is otherwise bad, the question will lie between 
arthrectomy and amputation. While amputation is, of course, 
to be avoided in children if at all possible, an arthrectomy of 
the knee where the abscesses are multiple or extensive, is a very 
serious matter on account of the necessarily prolonged nature of 
the operation, and consequently on account of the risk, and 
therefore, especially if there be tubercular lesions elsewhere, 
amputation may be the preferable procedure. In some cases, 
however, where the joint disease is the only lesion, and where 
the general state of the patient is good, one may begin by wash- 
ing out, scraping and injecting the abscesses, and then if it 
becomes necessary at a future time to perform arthrectomy, 
it will not be nearly such an extensive and dangerous 
operation. 

In adults, similarly, excision becomes a more serious operation, 
and in a good many cases amputation is preferable, especially 
when the patient is old, where the disease is progressing rapidly, 
or where there is tuberculosis elsewhere. Where the abscess is 
single, and the synovial thickening not markedly soft, it may 
be desirable to be content, in the first instance, with excising or 
washing out the abscess, and where excision of the joint seems 
desirable and the abscesses are large or multiple, one may 
reduce the extent of the subsequent operation by preliminary 
treatment of the abscess. 

In these, as in many other points in the treatment of tuber- 
cular diseases, it is impossible to lay down definite rules to fit 
every case, one can only indicate the principles which guide one 
in coming to a decision. 

(b) Sinuses. — The presence of septic sinuses complicates 
matters very much on account of the risk of sepsis, where 
arthrectomy or excision is performed. I have, however, now 



TREATMENT OF SEPTIC SINUSES. 281 

done a number of these operations successfully, where septic 
sinuses were present, and have thus been led to modify my 
former opinion that the presence of septic sinuses practically 
precludes the performance of arthrectomy. No doubt, however, 
it makes one hesitate to undertake it till all other means have 
failed. 

In children, unless deformity is present, or the suppuration 
profuse, or the pain great, we may, in the first instance, see what 
can be done by thorough fixation of the limb for a lengthened 
period. If there is no improvement, and the discharge slight, 
arthrectomy is indicated. Similarly if the discharge is slight, 
and the deformity marked, arthrectomy is the best procedure. 
If, however, the pain is great, the discharge profuse, and no im- 
provement occurs under expectant treatment, amputation is often 
necessary, and this is more especially the case if there is tuber- 
cular disease elsewhere, or if the health is suffering. If arthrec- 
tomy is done, the incisions are irregular, and one begins by 
dissecting out the sinuses entirely, and, before opening the joint, 
thoroughly sponging out their tracks with undiluted carbolic 
acid, and, if they communicate with the joint, sponging out the 
whole joint with carbolic acid before closing it. Drainage tubes 
should always be employed in this case lest the wound should 
become septic. "Where it is deemed advisable to employ ex- 
pectant treatment, the healing of the sinuses is often expedited 
by laying them freely open, scraping or clipping them out, 
applying undiluted carbolic acid, and stuffing them with gauze 
sprinkled with iodoform or soaked in balsam of Peru. 

In adults, one may, in some cases where the sinuses do not 
communicate with the joint, do as I have just said, viz. — open 
them up, clip them away, sponge with pure carbolic acid, and 
stuff with iodof ormed gauze. In most cases, however, one per- 
forms excision, taking the same precautions as regards the 
sinuses as I have just mentioned under arthrectomy, or if the 
discharge is profuse, the pain great, or tuberculosis elsewhere, 
amputation is often the best practice. 



282 DISEASE OF THE KNEE JOINT. 

4. Cases of primary synovial disease, where recovery is taking 
place with anchylosis, fibrous or bony, in a bad position. 

Here again the age of the patient is the most important 
point, and we shall take first patients who have not yet reached 
their full growth. Where the union is fibrous and the position 
bad an attempt may be made to rectify it under chloroform ; it 
is rarely that extension will succeed at this stage. The most 
common deformity is flexion of the knee, the head of the tibia 
being also drawn up behind the femur. As the hamstrings and 
structures behind the joint are shortened, it is seldom possible, 
either by extension or by force, to get the leg into proper 
position. It is a serious matter for the development of the limb 
that it should not be used, while on the other hand, to cut off 
portions of the bone, so as to allow the ends to come into good 
apposition is still more serious. In some of these cases one can 
get the leg straight by performing a systematic arthrectomy, 
dissecting away all the synovial membrane and new fibrous 
tissue, and especially removing the capsule posteriorly, in the 
systematic manner previously described ; if necessary the ham- 
strings may be divided, but after the posterior capsule has been 
removed the limb can generally be got straight without this. 
"Where this is impossible, or where the anchylosis is bony, I 
believe it is better, on the whole, either to leave matters alone 
till the patient is sixteen or seventeen years of age, i.e., till 
he is approaching his full growth, and then remove a wedge 
of bone or perform a typical excision, or, where the deformity 
is great, to divide the femur above the joint, and bring 
the leg straight. If the former plan is adopted, it is well 
to apply an apparatus which will prevent the flexion from 
increasing, and possibly straighten the limb somewhat. The 
apparatus must take a firm and extensive grasp of both 
the thigh and the leg, and be connected at each side of the 
knee by strong bars with rack and pinion joints, which can be 
altered from time to time, so as to cause extension. A very 
good wire splint is described by Bradford and Lovett, which 



TREATMENT OF BONE DEPOSITS. 



283 



will be sufficiently explained by the accompanying figure, taken 
from their book. There also will be found mentioned more 
elaborate forms of apparatus for straightening the joint, and 
at the same time preventing dislocation backwards of the tibia 
{see Fig. 44). 

In the case of adults there is no objection (except where 
there are sinuses or some other grave constitutional condition) 
to bringing the limb straight at once by operation, either by a 




Fig. 44. — Arrangement for straightening a bent knee. 
(After Bradford and Lovbtt.) 

typical excision or, if the disease has quite recovered, by remov- 
ing a wedge of bone of suitable size and shape. 



Treatment of Cases where the Disease has commenced 
primarily in the bone. 

1. In the early stage, before the joint has become affected, or the 
deposit reached the surface. — It is very seldom that one gets a 
case before the deposit has reached the surface, but sometimes 
patients come complaining of uneasiness and stiffness about the 



284 DISEASE OF THE KNEE JOINT. 

joint, with enlargement of some part of the bone. In cases 
where there is reason to suspect a tubercular deposit (tubercular 
disease elsewhere, pain not a marked symptom, absence of much 
aching at night, &c.) the best plan is to cut down on the 
thickened bone without delay, avoiding opening the joint, chisel 
away a portion of the outer shell of the bone, and scoop out 
some of the cancellous tissue. If cheesy material or a seques- 
trum is found this must be thoroughly removed, the cavity 
filled with iodoform and glycerine, and the skin wound stitched 
up, space being left at one end between the stitches for the 
escape of discharges. Should the wound not heal, and evidently 
become tubercular, it should be opened up again, scraped out, 
and stuffed with iodoformed gauze. Of course, in the case of 
children, special care would be taken to avoid injury to the 
epiphysial line as far as possible. 

2. In cases where the deposit has reached the surface outside the 
joint and led to the formation of an abscess in the soft parts the 
abscess should be dissected out, or if too large, laid open freely 
and the wall clipped and scraped away. The bone deposit 
should then be cleared out and the wound treated as in the 
former case. 

3. Where the deposit has readied the surface at the point of 
reflexion of the synovial membrane, and infected that membrane. — 
Where the thickening of the synovial membrane is limited to 
the neighbourhood of the deposit, then I think early removal 
of the whole affected area of synovial membrane, along with the 
bone deposit, is indicated. This, if done early, thoroughly, and 
aseptically, may ultimately leave the patient with a perfect 
knee-joint. 

Where the whole membrane has become affected one may, 
for a time, persevere with expectant measures, but if suppura- 
tion occurs, or the disease continues to progress, operation will 
be necessary, and the usual operations will be complete arthrec- 
tomy in children, the bone deposit being thoroughly cleared out 
as well, and excision in adults. Of course in bad cases, where 



TREATMENT OF BONE DEPOSITS. 285 

the bone disease is extensive or multiple, and abscesses are 
present, amputation may be necessary, but this will depend on 
the individual case, and the decision must be made on the lines 
already laid down. 

4. Where the deposit has opened into the cavity of the joint and 
infected the whole interior. — In this case the symptoms are more 
acute, and generally accompanied by pyarthrosis, and this con- 
dition is most intractable. In the early stage, especially in 
children, one may wash out the joint and inject iodoform 
emulsion, and if necessary employ extension. In these cases, 
however, unless it is a small, superficial, soft deposit, the 
chances of cure by these means are not good, and once it 
becomes evident that the bone deposit is larger, and especially 
that it is of the nature of a sequestrum, it is only losing time 
and running unnecessary risk to delay operation. This opera- 
tion would be arthrectomy in children, great care and patience 
being devoted to picking out all the bone deposit, and complete 
excision in adults, subject of course, to the possibility that 
other circumstances might necessitate amputation in either 
case. 



CHAPTEE XVIII. 

DISEASE OF THE ANKLE, TAESUS, AND 
METATARSUS. 

In adults the ankle and tarsus combined come fourth in the 
list of frequency of tubercular bone disease, forming from 10 to 
14 per cent, of the total number. If the ankle and tarsus are 
separated in my list, disease of the tarsus occurs more fre- 
quently than that of the ankle in the proportion of 40 to 23. 
In childhood, disease of the tarsus and ankle is not so common 
in relation to the other joints as it is in adults, and it is more 
evenly distributed over the first three decades than those for- 
merly mentioned. "We may, therefore, look on disease of the 
ankle and tarsus as mainly a disease of adolescence (10-30 years 
of age). 

As to the parts of the foot usually affected, the disease most 
commonly occurs in those parts which transmit the weight of 
the body to the ground, viz. — the ankle-joint, the os calcis, the 
head of the astragalus, and the proximal end of the first meta- 
tarsal bone. 

In the case of the ankle-joint, primary synovial disease is by 
no means uncommon, but the statements vary considerably as to 
the relative frequency. Munch found that, in 28 cases of disease 
of the ankle-joint alone, the disease was primarily synovial in 23, 
affected the tibia in the first instance in 1, and the astragalus 
in 4. Erasmus, on the other hand, found that, in 11 cases of 
disease of the ankle-joint, 2 were purely synovial, in 6 there 
was both synovial disease and caseous deposits in the bone (tibia 
alone in 2, astragalus alone in 2, astragalus and scaphoid in 1, 
and more extensive in 1), and in 3 sequestra were present. 
My own opinion is that primary synovial disease occurs more 



PARTS AFFECTED. 287 

often in the ankle than primary osseous disease, and that, of the 
various bones, the disease occurs most frequently in the astra- 
galus, and next in the inner and upper part of the malleoli, 
especially the internal. 

In the case of the tarsus, except in young children, the disease 
commences most often in the bone, but as regards the frequency 
with which the various tarsal bones are the primary seat of 
deposits, statements differ very much, and it is by no means 
easy, in an advanced case, to say where the disease commenced, 
as several bones generally show destructive changes. Czerny 
found, in 52 cases, that the astragalus was affected 15 times, 
the os calcis 13 times, the cuboid 16 times, and the scaphoid 
and cuneiforms 8 times ; but, as before stated, more than one 
bone was usually affected, and it was not always certain in 
which the disease commenced, or whether more than one bone 
may not have been attacked at the same time. 

The following are some other statements : — Munch found, in 
53 cases, that the astragalus was affected in 2 instances, the os 
calcis in 19, the scaphoid in 5, the cuboid in 3, the cuneiform 
in 2, the end of the first metatarsal bone in 12, and other 
metatarsal bones in 10. In 10 cases Dumont found 3 of 
primary disease of the astragalus, 4 of the os calcis, 1 of the 
scaphoid, and 2 of the cuboid. 

Of the various bones, the os calcis is undoubtedly most 
frequently attacked, and then the base of the first meta- 
tarsal; probably the cuboid comes next, then the astragalus, 
and the scaphoid and cuneiforms last. In the os calcis, 
soft caseous deposits are more frequent than sequestra; 
they usually occur towards the posterior part of the bone, 
but, as a rule, though not invariably, the projection of the 
heel escapes. 

Another point which is worth attending to is the fact that in 
the tarsus, almost more than elsewhere, bones which are not 
actually affected with the tubercular disease become much softer, 
in fact, are very apt to become affected with rarefying osteitis, 



288 ANKLE, TARSUS, AND METATARSUS. 

but this condition usually recovers when the diseased tissues 
are removed. 

The results of tubercular disease in the tarsus and ankle are ■ 
the same as elsewhere, allowing for the difference of locality, 
&c, and need not be gone into minutely here. 

Disease of the Ankle. 

I have already, in the case of the hip and knee-joint, gone 
very fully into the symptoms and course of the disease in rela- 
tion to the pathological changes in a deeply seated and a super- 
ficial joint respectively, and it would only be unnecessary 
repetition were I to follow the same lines in the ankle. I 
propose, therefore, merely to indicate the chief characteristic 
points. 

The synovial thickening is most evident in front of the joint, 
and more especially in front of the external malleolus, where 
the synovial membrane is not so much bound down by tendons 
as on the inner side. The extensor tendons are also projected 
forward, and the swelling extends downwards for quite an inch 
on the front of the foot. Behind the ankle also, on each side 
of the tendo achilles, fulness can usually be made out. There 
may also be fulness below the malleoli when the disease is 
advanced, and the lateral ligaments softened and bulged out by 
the thickened membrane; but in the early stage, before the 
lateral ligaments are softened, there is no or only a very slight 
fulness below the malleoli. The character of the synovial thick- 
ening and the course of events is similar to what has been 
already described in the knee. 

Where the disease commences in the bone, there is marked 
thickening of the part, especially noticable when one or other 
malleolus is affected ; and where the synovial membrane is not 
at the same time thickened, the appearance at first sight is as 
if the foot had been displaced to one side, being where the 
internal malleolus is involved not unlike a Dupuytren's 



DISEASE OF THE ANKLE JOINT. 289 

fracture. The primary deposits in the astragalus are not so 
easy to diagnose ; the thickening of the astragalus is obscured 
by the synovial swelling, and, besides, as a rule, the deposits in 
the astragalus are small, and situated immediately beneath the 
cartilage, and do not give rise to much swelling of the bone. 
In some cases, however, oDe can make the diagnosis by the pain 
and rigidity and marked localised thickening of the synovial 
membrane at the part where the deposit has reached the sur- 
face, usually in front of one of the malleoli. 

Where no retentive apparatus is employed, the chief deformity 
which occurs is pointing of the toes. A condition of inversion or 
eversion, especially the latter, is also sometimes produced where 
the lateral ligaments have become softened, permitting lateral 
mobility, or where one or other malleolus has become much 
thickened, pushing the foot to the opposite side. 

The pain depends, of course, on the degree of inflammation of 
the bone, and, when there is much caries, it is very marked when 
the foot is allowed to hang down or is moved or pushed up. 

If we see a case of synovial disease of the ankle joint in the 
early stage, we find fulness under the extensor tendons and 
on each side in front of the malleoli, especially the external ; 
there is also swelling behind the ankle ; there is a tendency to 
pointing of the toes, but the movements of the joint are fair, and 
pain is not a prominent symptom. In the early stage of bone 
disease, we have enlargement of one or other malleolus without 
thickening of the synovial membrane : or a more or less localised 
thickening with pain on movement of the joint, and tenderness 
on pressure (where the deposit is in the astralagus) : or a more 
acute affection of the joint with great pain on movement, 
rigidity, but without marked synovial thickening in the first 
instance ; fluid (serous or purulent) may also be present in the 
joint at an early period. 

In the later stages of joint disease, in whichever way origin- 
ating, the whole region of the joint is swollen and spindle- 
shaped (see Fig. 45), the toe is pointed, the muscles of the calf 

19 



290 



ANKLE, TARSUS, AND METATARSUS. 



are much atrophied, there is great pain on hanging down the 
foot, and on any movement or pressure ; and abscesses or sinuses 
are very generally present, usually on the antero-lateral aspects 
of the joint. It is not uncommon also at this stage for the 
extensor tendon sheaths to become affected, and then we have a 
tubercular tenosynovitis. 

Where recovery takes place, unless at an early stage, there is 
usually fibrous or bony anchylosis in the 
extended position. In some cases where 
the disease has occurred in children, and 
has been in the form of a deposit in one 
or other malleolus, the epiphysial line 
becomes destroyed, and as growth goes 
on that bone lags behind, and conse- 
quently the foot becomes pushed over to 
the inner or outer side by the other bone 
in which the growth is more or less normal. 

Disease of the Tarsus. 

Os calcis. — As I have already said, the 
os calcis is probably the tarsal bone most 
frequently affected, and it is also the 
most favourably situated in that the 
disease very often remains limited to it, 
or to its immediate joints, especially the 
astragalo-calcanean, and does not spread 
to the tarsus generally.' The part of 
the bone most commonly affected is the substance of the 
bone in the neighbourhood of (in front of) the posterior epiphy- 
sial line, and the posterior epiphysis to which the tendo achilles 
is attached usually escapes. It may, however, begin near the 
astragalo-calcanean joint, and open into it or under the perios- 
teum, giving rise, in the latter case, to a tubercular periostitis, 
with abscess and caries of the surface of the bone. It is rare 




Fig. 45. — Disease of 
the ankle-joint. (After 
Bradford and Lovbtt.) 



DISEASE OF OS CALCIS. 291 

for the disease to begin in connection with the calcaneo-cuboid 
joint. The disease is comparatively easily diagnosed by the 
position of the swelling. Where the substance of the bone is 
affected, the whole bone is swollen, and there is some aching 
pain in it, though not usually of the severe and constant 
nature characteristic of abscess in the bone. By-and-bye the 
deposit reaches the surface somewhere, and an abscess forms 
over it, and the subsequent sinus leads into the interior of the 
bone. Where the disease begins in connection with the perios- 
teum, there is only a localised thickening, over which an abscess 
forms, and here the probe simply leads to the carious surface of 
the bone. Where the astragalo-calcanean joint is involved, 
there is swelling at the level of that joint and of the adjacent 
bone to a greater or less degree according to the depth of the 
deposit, with pain on grasping the os calcis, and pushing it up 
or attempting to displace it laterally. At the same time, the 
ankle-joint and the anterior tarsal joints remain free. Where 
the calcaneo-cuboid joint is attacked, the swelling is on the 
outer side of the foot midway between the tip of the external 
malleolus and the base of the fifth metatarsal bone, with 
thickening over the os calcis behind, and there is pain on moving 
the transverse tarsal joints, and absence of swelling elsewhere. 
In cases where the midtarsal joints, as a whole, are involved, 
there is a great tendency to abduction of the anterior part of 
the foot, the arch is lost, and there is marked enlargement, and 
especially increase in breadth of the middle of the foot. 

Where the midtarsal bones, scaphoid or cuneiforms, are 
affected or the synovial membrane between them, it is not 
so easy to make out the chief and originating source 
of the mischief unless one sees the cases at an early stage. 
Where the swelling is on the inner side of the foot, and extends 
from in front of the ankle to the metatarsus, then the scaphoid 
is probably the bone primarily at fault ; absence of swelling 
about the ankle-joint shows that that part is not affected ; the 
absence of swelling on the outer side of the foot shows that the 



292 ANKLE, TARSUS, AND METATARSUS. 

cuboid and the calcaneocuboid joint are unaffected ; while the 
presence of swelling both in the astragalo-scaphoid joint and in 
the region of the cuneiform bones, makes it extremely probable 
that there has been disease in the substance of the scaphoid, 
which has infected the joints on each side of it. 

Where the head of the astragalus is the primary seat of 
disease, the swelling is limited to the astragalo-scaphoid 
joint in the first instance. Where one or other cuneiform, or 
the synovial membrane in relation with them is affected, the 
swelling is on the distal side of the scaphoid. Where the 
disease has commenced in the proximal end of the first meta- 
tarsal bone, that part is the seat of thickening which soon 
tends to spread to the region of the cuneiform bones. 

It is not always easy to say whether the disease is primarily 
osseous or primarily synovial, because the bones are small, and 
the synovial membrane generally early affected. Where the 
synovial membrane is affected primarily the swelling is usually 
more diffuse in the first instance, and pain is not a marked 
symptom. 

So far, I have described the disease as it begins when limited 
to one part of the tarsus, and it is most important from the 
point of view of treatment, to look for and recognise the early 
manifestations of the disease. As a rule the commencement is 
as I have described, but in a certain number of cases the disease 
begins in the form of a diffuse osteomyelitis, affecting apparently 
several of the bones, and this is a very grave form of the 
disease. I believe that it most often follows sprains or other 
injuries to the foot, and its seriousness depends both on the 
extent of the bone lesion, and on the great tendency to secondary 
disease elsewhere. As a matter of fact phthisis follows or 
accompanies disease of the ankle and tarsus more frequently 
than disease of any other part, with the exception of the wrist, 
and it is not improbable that it is this diffuse infection of 
medullary tissue which has to do with the spread of the 
disease. 



TREATMENT OF ANKLE JOINT DISEASE. 293 

One other point is of importance in connection with disease 
of the tarsus and ankle, viz. — that the disease is apt to attack 
the tendon sheaths in the vicinity, and thus gravely complicate 
the treatment of the case. This is more especially the case in 
disease of the tarsal bones, such as the scaphoid and internal 
cuneiform, where the sheaths of the tendons become infected by 
direct extension from the periosteum. 

Treatment of Ankle Joint Disease. 

A comparatively short description of the treatment of disease 
of the ankle-joint will suffice, after the full discussions on the 
various points which have already been given. 

Various splints are recommended for giving rest to the joint, 
but I believe the most satisfactory arrangement is by lateral 
poroplastic or gutta percha splints, carefully moulded to the 
part and padded with cotton wool. Care must be taken in any 
form of apparatus that the foot is kept at right angles to the 
leg, so that should stiffness occur, the sole can be placed flat on 
the ground. A paper pattern of the foot and leg are taken, and 
the poroplastic splints are cut out to match ; they should not 
quite meet. At the anterior angle corresponding to the front 
of the ankle, a small additional angular piece must be cut 
out, so as to allow proper moulding, and if it is necessary to 
soften any part to avoid pressure, this can be done by chloroform 
or benzole. The splint should extend as high as the tuberosity 
of the tibia, and as far as the toes, and should get a good grasp 
on the heel and sole of the foot. The poroplastic material is 
softened before application either by dry heat or steam (in a 
bacteriological sterilising apparatus) not by hot water. A layer 
of wool is applied around the leg, and the splints rapidly 
moulded and bandaged on, one at a time, and re-softened by 
heat where necessary ; subsequently any points of pressure on 
bony prominences can be softened by chloroform, but this is 
seldom required if the parts are properly padded. 



294 ANKLE, TARSUS, AND METATARSUS. 

Thomas recommends a flat iron stem moulded to the back of 
the leg and the sole of the foot, with three sheet iron wings, one 
broad one at the calf, one grasping the heel, and one grasping 
the metatarsus, and if the patient is to be allowed to walk 
about, a Thomas's walking knee-splint and crutches. I do not 
think this is so good as the arrangement just referred to. 

Where the disease is fairly quiescent the use of immovable 
apparatus, such as plaster of Paris, or, better, silicate, is good. 
Where silicate is used one may sometimes employ pressure on 
Saxtorph's plan with benefit. The affected part is enveloped 
in a very large mass of cotton wool or silk waste (the latter is 
the more elastic), and the boracic lint bandage which extends 
as far as the silicate is put firmly over this. The silicate 
bandages are then applied as tightly as possible over the cotton 
wool area ; if a sufficient amount of wool has been used this 
pressure will not be excessive. These bandages are renewed 
every six or eight weeks, but if they cause much aching and 
discomfort they should be discontinued at once. 

Arrangements have also been introduced with the view of 
employing extension in ankle-joint disease. They consist essen- 
tially in sandals fastened to the foot and heel, and attached to 
pulley and weight ; but they are inefficient, and where the 
symptoms are such as to demand extension, operation, which is 
free from danger and satisfactory, is preferable. 

The cases suitable for operation are similar to those described 
in the case of the knee-joint, viz. — distinctly localised deposits, 
advancing synovial or bone disease, and cases where suppuration 
is present. 

Practically the only localised deposits which come under 
observation are those in the malleoli, which have made their 
way outwards instead of into the joints. By some these are 
considered under a separate heading, as disease of the malleoli ; 
but, as a matter of fact, they really belong to the ankle-joint, 
it being merely an accident of position of the deposit that it 
has spread outwards instead of into the joint. Where one has 



ARTHRECTOMY OF ANKLE. 295 

made the diagnosis, from the thickening of the malleolus and 
the absence of acute signs and of involvement of the joint, that 
there is a deposit in the bone, the proper treatment is to cut 
down, remove the outer shell of the bone, and gouge out the 
diseased tissue, taking caje not to go through into the joint. 
Where an abscess is also present, the matter is, of course, easier, 
because the hole in the bone guides one at once to the seat 
of the disease. In this case the abscess wall is taken away, the 
bone deposit cleared out, and if a sinus has been previously 
present,. it is best afterwards to stuff the cavity with iodoformed 
gauze and make it heal from the bottom. 

Where the joint is affected with or without a deposit in the 
bone, the usual operation for childhood is arthrectomy. There 
are numerous ways of performing arthrectomy of the ankle-joint 
(some thirty-seven or thirty-eight), but I think they may be 
reduced to two. In both, longitudinal incisions are made in 
front of each malleolus, and in the one the malleoli are divided 
at their bases, in the other the astragalus is removed. These 
methods are suitable in different cases, but I believe the latter 
is the more generally useful. The excision of the astragalus is 
best where there is a primary deposit in the bone, where the 
disease of the synovial membrane is extensive and rapidly 
breaking down, or where there is extensive caries of the surface 
of the astragalus. The division of the malleoli may be employed 
in the earlier stages of the disease, and especially in cases 
where there is no deposit in the astragalus, and where the car- 
tilage is still intact, or only slightly destroyed. The objection 
to division of the malleoli is the risk of interference with the 
epiphysial lines, and this is a real objection. Against the ex- 
cision of the astragalus is urged the bad effect of removal of 
one of the chief bones, subsequent shortening of the foot, and 
possible lateral deformity. I have now removed the astragalus 
on several occasions, and the results have been very satisfactory. 
The os calcis has been drawn up between the malleoli, and a 
movable joint has been obtained without any laxness, and I 



296 ANKLE, TARSUS, AND METATARSUS. 

have as yet seen no sign of shortening of the foot, and in cases 
where it has heen observed by others, it has not been great. 
In one or two cases I had to take considerable pains to guard 
against inversion of the foot, but that tendency passed off after 
some months. A 

The following are the steps of the operation where the bases 
of the malleoli are divided. The incisions commence from 1 
to 2 inches above each malleolus, run downwards along their 
anterior borders to the bend of the ankle, and then forwards 
along the inner and outer borders of the foot respectively, as 
far as close to the midtarsal joint. The various structures in 
front of the ankle are then detached from the thickened synovial 
membrane and held forward, while all the thickened membrane 
in front of the joint is removed. The bases of the malleoli are 
then divided obliquely from above, downwards and inwards, the 
periosteum being left intact, and then, by pulling the foot 
forcibly downwards and rotating it first in one direction and 
then in another, the lateral and posterior portions of the 
synovial capsule are clipped away. The bones are then care- 
fully examined, and any deposits or suspicious spots removed ; 
finally, the divided malleoli are brought into position, and 
secured by pegs or wire. It is difficult, in most cases, to 
thoroughly clear the posterior part of the joint by this method, 
but advantage may be gained by a vertical incision along the 
outer border of the tendo achilles into the posterior part of the 
joint. In the other plan the incisions are the same, but instead 
of cutting through the malleoli, the lateral ligaments are 
divided, and without any trouble, the astragalus can be removed 
entire, and the interior of the joint much more accurately dealt 
with. After the operation the wounds are stitched up and 
treated as before described, and it is well to employ a lateral 
splint, or other means, to prevent eversion or inversion of the 
foot for some months, till, in fact, the parts have thoroughly 
consolidated. 

While arthrectomy of the ankle-joint is an operation especially 



AMPUTATION FOR ANKLE DISEASE. 297 

of childhood, it succeeds very well also with adults, especially 
when combined with removal of the astragalus. I believe that 
on the whole the results are better in adults than those of 
excision which, though formerly much practised, did not yield 
particularly good results in cases of tubercular disease. Where 
excision is performed without removal of the astragalus, the 
incisions and procedure are practically the same as in the first 
of the operations of arthrectomy. After the joint has been 
exposed by division of the malleoli, and as much of the synovial 
membrane as possible removed, a layer of the surface of the 
bones is chipped away by a chisel and hammer, leaving the 
arched shape of the lower end of the bones of the leg, the 
remains of the malleoli being subsequently wired to the tibia 
and fibula. By retaining the shape of the ankle-joint, there is 
less tendency to lateral displacement should a movable joint be 
obtained, and the retention of the external malleolus is of 
especial importance. Excision of the ankle, as formerly per- 
formed, that is, without thorough removal of the affected 
synovial membrane, was not at all a successful operation in 
tubercular disease, and most surgeons preferred amputation 
where operation was necessary. 

"Where amputation becomes necessary on account of the 
extent of the disease, the destruction of bone, involvement of 
tendon sheaths, presence of phthisis, &c, the choice usually lies 
between Syme's operation and amputation through the leg. 
Formerly, Syme's amputation was performed in all cases, and 
the result was that not unfrequently sinuses remained, and 
further portions had to be removed from the bones of the leg. 
This was no doubt due to the fact that the diseased synovial 
membrane was usually cut into and portions left, and also to 
the employment of the operation in unsuitable cases. Where 
Syme's operation is performed, great care must be taken that 
all the diseased tissues, both synovial membrane and bone, are 
completely removed. Where the disease of the bones of the leg 
is extensive, where the tendon sheaths are affected, where there 



298 ANKLE, TARSUS, AND METATARSUS. 

are large abscesses around the joint, where, in fact, Syme's 
amputation cannot be performed without leaving behind diseased 
tissues, the best procedure is to amputate through the leg above 
the diseased parts. 

Treatment of Disease of the Tarsus. 

I need not dilate on the treatment whexe rest is resolved 
upon. I believe that either lateral splints or a mass of wool 
and silicate bandage extending up to the knee are the best, the 
leg not being allowed to hang down. I must, however, go more 
fully into the question of operative treatment, and operation 
comes earlier and more prominently into notice than in the 
joints previously referred to, and that for several reasons. On 
the one hand, disease of the tarsus is a more unfavourable form, 
both locally and generally if left to itself, than that of the 
joints previously considered, on account of. the complexity of 
the articulations, of the frequent and diffuse bone lesions, and 
of the tendency to lung mischief. On the other hand, the 
disease is frequently localised to one part or bone of the tarsus 
in the first instance, and if this is removed before neighbouring 
structures have become infected, a complete cure of the disease 
will often be obtained with an excellent functional result. 
Hence, it is of great importance to bear in mind what can be 
done by early operation, to recognise the disease soon, and not 
to let the favourable moment slip past. I may indicate some 
of the points in the operative treatment of the following con- 
ditions, viz. — disease of the os calcis ; of the proximal end of the 
first or other metatarsal bone ; of the internal cuneiform ; of the 
cuboid ; of the astragalo-scaphoid articulation ; of the scaphoid 
and the joints in front and behind ; of the whole tarsus ; of the 
tarsus and ankle. 

(a) Disease limited to the os calcis. In the early stage, where 
the disease is confined to the interior of the bone, one may 
delay operation for some time, but when it has reached the 



TREATMENT OF TARSAL DISEASE. 



299 



surface of the bone and led to the formation of an abscess over 
it, the proper treatment in the first instance is to remove the 
abscess, enlarge the opening in the bone freely, scoop out the 
diseased tissue and stuff the cavity with iodoformed gauze and 
make it heal from the bottom. The same is the treatment 
where a sinus is present. Excision of the entire bone becomes 
necessary where healing will not occur (see Fig 46) ; where the 
disease is extensive, several abscesses or sinuses being present ; 
or where it has spread to the neighbouring joints, either 




Fig. 46. — Result of excision of the os calcis. 

calcaneo-cuboid or -astragaloid. Where, on the other hand, the 
disease is periosteal, an immediate cure can generally be obtained 
by dissecting or clearing out the abscess and removing freely 
the affected area of periosteum and the surface of the bone. 

(6.) Disease of the proximal end of the metatarsal bones. — 
Where the disease occurs in the interior of the bone the best 
treatment is to remove the affected end of the bone before 
the neighbouring joints have become involved. This is readily 
done, in the case of the first metatarsal bone, by a longitudinal 
incision a little to the inner side of the extensor tendon, turning 



300 ANKLE, TARSUS, AND METATARSUS. 

aside the soft tissues, partially dividing the bone in front 
with a small saw, and completing the division with bone 
forceps, seizing the divided end of the bone with necrosis 
forceps, and cutting through the various ligaments holding it in 
position ; one must make sure that the whole deposit is removed. 
The incision may then be stitched up and the patient prohibited 
from walking on the foot for about three months after the 
operation, so as to give time for thorough consolidation of the 
parts to occur. This operation does not interfere with the 
function of the foot. 

(c.) Disease of internal or middle cuneiform, or of neighbouring 
synovial membrane. — Where the disease is limited to these 
structures, I would strongly advise early removal of the internal 
cuneiform alone or of the internal and middle cuneiform, 
along with all the affected synovial membrane, the wound being 
stitched up if aseptic, or stuffed and made to heal from the 
bottom if sinuses are present. The parts are readily reached 
by a longitudinal incision over the inner side of the dorsum of 
the foot. The results of this operation are particularly ex- 
cellent, and I have now several cases where I removed these 
bones some years ago, with complete success as regards arrest 
of the disease, and where at the present time one could not tell 
that anything had been taken away, or, beyond the presence of 
the cicatrix, that anything had ever been the matter with the foot. 

(d.) Disease of the cuboid. — The treatment of disease limited 
to this bone is conducted on similar principles to that of disease 
of the os calcis, deposits being cleared out if they are limited to 
the interior of the bone, or the whole bone being removed if 
necessary. 

(«.) Disease of the astragalo-scaphoid articulation. — Where 
disease is limited to this joint it has either begun in the synovial 
membrane or in the head of the astragalus, and removal of the 
synovial membrane and head of the astragalus generally suffices 
with the necessary attention to the articular surface of the 
scaphoid. The joint can be got at by an oblique incision along 



TREATMENT OF TARSAL DISEASE. 301 

the inner border of the tendon of the tibialis anticus, and it is 
not as a rule necessary to divide that tendon. 

(/.) Disease of the scaphoid and the joints in front and hehind. 
— Here we come to the more diffuse disease, and much depends 
on the exact condition of parts how much requires removal. In 
any case the scaphoid must be taken away, and generally one 
or two cuneiforms. I have in two or three cases removed the two 
innermost cuneiforms, the scaphoid, and the head of the astra- 
galus, and the hole has filled up with dense fibrous tissue and 
an excellent result has been obtained. These parts are easily 
got at by a longitudinal incision along the inner part of the 
dorsum of the foot, and the tendon of the tibialis anticus 
requires division. 

(g.) More diffuse disease of the tarsus. — So far I have been 
speaking of cases where typical excisions can be done, and 
wherever it is possible to remove a definite structure by clean 
dissection it is infinitely preferable to scraping which is, I believe, 
the usual practice. Once one begins to scrape at diseased bone 
one loses one's guides, and the result too often is that portions 
of diseased tissue are left behind, and too much healthy tissue 
is removed. Besides, as I have already pointed out, diseased 
synovial membrane cannot be satisfactorily removed by scraping. 
Hence, wherever it is possible the surgeon should make up his 
mind what structures are diseased, and then remove them by 
clean dissection. Where the disease is more diffuse, and especi- 
ally where it affects the synovial membranes, it may be possible 
to do good in cases where operation is necessary by less typical 
removal of affected tissue. Where an attempt is to be made to 
save the foot and the mid-tarsus is involved, probably the best 
way of proceeding is by a transverse incision across the dorsum 
of the foot, dividing all the structures down to the bone, a 
longitudinal incision being made at each end of this along the 
inner and outer borders of the sole. These flaps are then turned 
upwards and downwards, the bases of the metatarsal bones below 
and the ends of the astragalus and os calcis above sawn across, 



302 ANKLE, TARSUS, AND METATARSUS. 

and the block of bone comprising scaphoid, cuneiforms, cuboid, 
and ends of metatarsals, &c, removed. If no sinuses were 
present the tendons may be reunited, the wounds stitched up, 
a drainage tube being inserted, and the foot arranged so that 
the anterior part is drawn up against the posterior. "Where 
sinuses are present the wound would be left open and stuffed 
with iodoformed gauze. The result is really very good, the 
anterior part of the foot gets drawn up and firmly united 
to the posterior, and the patient has a good firm support. 

In some instances it may suffice to take out a smaller wedge 
of bone, but this must be decided in the individual case. The 
block of bone may also be removed by long lateral incisions, 
but the operation is more troublesome and it is very difficult to 
remove all the disease satisfactorily. On the other hand the foot 
left after the transverse incision across the dorsum is in reality 
a very good one, and the tendons can be shortened to the 
necessary extent before stitching them. 

Where amputation is necessary the choice rests between a 
Syme and a Pirogoff, or some partial amputation of the foot such 
as sub-astragaloid amputation. I believe that in most cases the 
Syme will yield the best result, but the sub-astragaloid amputa- 
tion is very satisfactory in suitable instances. 

(K) Disease of the tarsus and ankle. — Where the disease 
involves the posterior part of the tarsus and ankle-joint, and 
operation becomes necessary, our choice practically lies between 
amputation (Syme, or in leg) and the operation known as the 
Mikulicz-Wladimiroff excision. This operation is only applic- 
able to adults, because in it the epiphysial lines of the tibia and 
fibula are taken away. It consists in removing all the bone 
between the scaphoid and cuboid, which are sawn through, and 
the divided lower extremities of the tibia and fibula. The toes 
are previously bent forward at right angles to the metatarsal 
bones, the divided tarsal bones are brought into a line with and 
united to the bones of the leg, and the patient walks on the toes. 
The following is a more detailed description of the operation : — 



MIKULICZ-WLADIMIROFF EXCISION. 303 

Before the operation is commenced the toes are bent violently 
forward to a right angle with the foot. The patient being then 
placed on his face, an incision is made, commencing on the 
inner border of the foot, a little in front of the tubercle of 
the scaphoid, and is carried transversely across the sole to just 
behind the tuberosity of the fifth metatarsal bone, dividing all 
the structures. From the ends of this incision the knife is 
carried back on each side to the corresponding malleolus, and 
then transversely across the posterior surface of the lower 
part of the leg. The ankle-joint is then opened from behind, 
and the foot being flexed, the astragalus and os calcis are care- 
fully removed along with the soft parts. The joint surfaces of 
the tibia and fibula are then sawn off, as well as the joint 
surfaces of the scaphoid and cuboid. The front half of the 
foot is thus left connected to the leg by a broad bridge, com- 
posed of the skin of the dorsum of the foot, with the extensor 
tendons, and vessels. After having arrested the bleeding, the 
remains of the foot are placed in the line of the leg, and the 
cut surfaces of the tarsal bones are united by wire sutures to 
the cut surfaces of the bones of the leg. Care has to be taken 
by means of a back splint to prevent the foot passing back- 
wards, and at a later period the flexor tendons may have to be 
divided, so that the toes remain at right angles to the meta- 
tarsal bones. The patient walks on the ends of the metatarsal 
bones, and the presence of the toes gives a certain amount of 
spring in walking. The leg is, however, somewhat longer than 
the other, and the ends of the metatarsal bones are apt to become 
painful. On the whole, I doubt if the patient is much better 
off than after a Syme's amputation. This operation may be 
extended to cases where the anterior part of the tarsus is also 
affected, the division of the distal bones being made through 
the bases of the metatarsals. Eoser dissects out the posterior 
tibial nerve in the first instance, as he fears neuroparalytic 
phenomena from its division and imperfect union. 



CHAPTEE XIX. 

DISEASE OF THE SHOULDER JOINT. 

Tubercular disease of the shoulder-joint is essentially a disease 
of adult life. It sometimes, but rarely, occurs before ten, but 
the usual age is between twenty and thirty. It is much more 
infrequent than disease of the joints already considered. In my 
list the cases of shoulder-joint disease only form 1-3 per cent, of 
the whole, and this corresponds to other results, for instance, on 
putting together a large number of cases from different authors, 
shoulder-joint disease only occupies 1"5 per cent, of the whole. 
Like disease of the tarsus and wrist, disease of the shoulder- 
joint is very commonly associated with phthisis. 

The disease is most often primarily osseous, and caries sicca 
is not uncommon, in fact this is the joint in which it usually 
occurs. The osseous deposits occur most often in the head or 
great tuberosity of the humerus, and sometimes, though rarely, 
in the neck of the scapula. The chief destructive changes 
involve the head of the humerus, which may in some cases be 
completely separated from the shaft ; in other cases the glenoid 
cavity may disappear, and the neck of the scapula be extensively 
affected. In bad cases the acromion may also be attacked, 
secondarily to disease in the bursa under the deltoid. 

The earliest symptom of disease of the shoulder-joint is 
usually pain. This pain is often of a neuralgic character, 
shooting down the arm as far as the elbow, and more especially 
following the course of the musculo-spiral nerve. There is 
also aching pain about the shoulder. There may be tender- 
ness in front of or behind the joint, and sometimes at the 
insertion of the deltoid. These symptoms become worse as the 
cartilages are destroyed, unless the arm is kept at rest, and 



SYMPTOMS. 305 

even then the patient is not necessarily free from uneasiness. 
The pain is to a great extent due to pressure on the nerves by 
the distended or thickened capsule, and hence the musculo- 
spiral is one of the first to suffer. In addition, a certain amount 
of neuritis is no doubt set up in a good many cases. The pain 
is also excited by movements, more especially by rotation of 
the limb. 

The swelling of the capsule is not very marked as a rule, 
partly because the muscles around the joint conceal it, and 
partly because the deltoid atrophies from an early period, 
and thus the swelling is masked. One can generally, however, 
make out if the capsule is swollen or distended by the greater 
rotundity of the shoulder, the hollows being filled up, especially 
the groove between the deltoid and the pectoralis major. In 
the axilla also one can feel that there is a soft pad between the 
fingers and the head of the bone corresponding to the thickened 
capsule. Where the bursa under the deltoid is involved in 
the disease, as sometimes happens, there is, of course, marked 
fulness around the outer side of the joint. 

In the early stage of pure synovial disease movement is only 

restricted, not completely abolished, and the arm is kept a little 

out from the side and somewhat flexed, and rotated outwards. 

The shoulder at the same time droops, and the arm appears 

longer, or may indeed be actually slightly longer, as measured 

from the tip of the acromion to the external condyloid 

process. As time goes on the second stage is reached, the 

bone becomes inflamed, and the muscles around the joint 

become contracted ; abduction of the limb gives place to 

adduction, and we find the arm closely applied to the 

side, rotated inwards and quite rigid; the shoulder is also 

elevated from contraction of the trapezius, and there is apparent 

and ultimately real shortening. At this stage no movement 

takes place between the humerus and the scapula, the apparent 

abduction of the arm, which may be produced, being entirely 

scapular movement. The atrophy of the deltoid becomes very 
20 



306 DISEASE OF THE SHOULDER JOINT. 

marked, and the shoulder becomes flattened, especially where 
the bone is the primary seat of the disease. Where this wasting 
has gone on to a considerable extent, the head of the bone looks 
as if it were displaced forwards towards the coracoid process, 
but, though in some cases the head may be a little too far for- 
wards, it is not as a rule really so ; it is merely that the muscles 
at the back of the shoulder have wasted, and left a hollow 
there. This appearance is especially well marked in cases of 
caries sicca. True dislocation of the shoulder-joint in tubercular 
disease is extremely rare, but cases have occurred. 

In the third stage of disease of the shoulder-joint we have the 
formation of abscesses, and the occurrence of suppuration in the 
joint or in the bursa under the deltoid. One of the common 
courses for the pus to take is along the long tendon of the biceps, 
pointing about the middle of the arm. Another frequent place is 
at the lower and posterior border of the deltoid, about the posterior 
fold of the axilla, or it may also show at the lower and anterior 
border of the same muscle, or, again, it may point in the axilla. 

As I have already said this is the chief joint in which the 
form of disease described by Volkmann as caries sicca occurs. 
This has already been described on p. 64, and may be looked 
on as a tubercular osteomyelitis of the head of the bone. The 
characteristic lesion is the atrophy of the bone, often going on 
to a considerable extent before the cartilage is destroyed, without 
any marked synovial thickening, or without suppuration, except 
in a few instances towards the termination of the case. Here 
flattening of the shoulder from wasting of the deltoid is an early 
feature, and a very marked one, because there is no synovial 
thickening to make up for it. Eigidity also occurs very early, 
and the trouble ultimately ends in bony anchylosis. 

The diagnosis of tubercular disease of the shoulder- joint is 
not always easy at an early period, and especially where it does 
not begin in the synovial membrane. The chief difficulty is to 
distinguish it from rheumatoid arthritis, and in the early 



TREATMENT. 307 

stage this may be almost impossible. In cases of tubercular 
synovial disease the presence of marked swelling of the soft 
tissues of the joint and absence of grating are opposed to 
rheumatoid disease. On the other hand, in primary bone 
disease there is much greater rigidity of the joint from the 
first than in the rheumatoid joint. In the rheumatoid arthritis 
there is a good deal of movement, and grating or crackling in 
the joint without very much pain. The pain occurs in exacerba- 
tions, and is worse after a period of rest, and often also at night. 
Of course the presence of other tubercular lesions increases the 
probability of tubercular joint trouble. Another difficulty is 
where a patient has had a fall on the shoulder, from which he 
dates his trouble. Here we may have simply adhesions in the 
joint, tubercular disease, or rheumatoid arthritis. The diagnosis 
from adhesions is sometimes very difficult in the early stage, 
especially where, on the idea that there was some inflammation 
going on, blisters and other counter irritants have been applied, 
and led to thickening of the tissues. One must be guided by 
the amount of thickening, by presence or absence of pain on 
jarring the arm or shoulder (absent in the case of adhesions), by 
the degree to which movements are restricted and painful, by the 
presence or absence of pain when at rest, especially of neuralgic 
pain down the arm, &c. The diagnosis can be made surer by 
putting the patient under an anaesthetic, when the adhesions 
can be broken down if present. 

Treatment of Shoulder Joint Disease. 

The principles of treatment are, of course, the same as else- 
where, and I need only refer to a few points. In the first 
place, in fixing the arm, a position must be chosen which will 
be a useful one, as the joint is generally more or less com- 
pletely stiff after recovery. What one usually finds is, that 
the arm is fixed to the side, the elbow being at right angles, 
and the arm rotated inwards so that the hand lies on the 



308 DISEASE OF THE SHOULDER JOINT. 

chest. The result is that the range of clavicular move- 
ment is not sufficient to enable the patient to raise the 
arm to a useful distance from the side, while the patient is 
unable to rotate his arm outwards, and the function of the 
hand is interfered with. It must, therefore, be put up con- 
siderably abducted, and this is done by a wedge-shaped pad in 
the axilla, extending down to the elbow. 

The arm must also be rotated outwards, so that the forearm 
projects forward in a line with the antero-posterior axis of the 
body, in order that the hand may be moved freely clear of the 
side of the body. The best way is, having arranged the wedge 
as just mentioned, to bend the elbow to right angles and rotate 
the arm outwards, and then to put up the whole, including the 
elbow and part of the forearm, in silicate or plaster of Paris 
bandages, renewing these as they become loose. If it is 
desired to make any applications to the shoulder, it can be 
left uncovered. 

In some cases, especially of bone trouble and in caries sicca, the 
use of the actual cautery is of great benefit in giving immediate 
relief of pain. The broad cautery should be applied in front of 
and behind the joint, and the wounds treated as before described. 

The employment of extension by weight and pulley is also 
sometimes useful, the patient lying in bed with the arm about 
half-way between flexion and extension, and also midway as 
regards rotation. Various arrangements have been made for 
keeping up extension while the patient is walking about, and 
they may be of use in suitable cases. I think, however, that 
the question of operative interference may with advantage be 
considered comparatively early in disease of the shoulder-joint. 

"Where abscesses have formed, the treatment depends on the 
answer given to the question of operation, which we may, 
therefore, now refer to. "With few exceptions, the disease is 
one of adult life, and, therefore, the question we have to refer 
to is that of excision. I may at once say that in a good many 
cases I believe much time will be saved by early excision, and 



EXCISION. 309 

a more useful arm will result. When the disease has passed 
beyond the first stage, the joint will, on recovery after ex- 
pectant treatment, be more or less completely stiff, and it 
is a matter of the greatest difficulty to get anchylosis in a 
really useful position. The patient is going about, dressing 
and undressing, and constantly tending to shift the arm, or 
grumbling if it is kept too far out from the side, or if the fore- 
arm projects forwards ; and this has to go on for many months 
or years. At the same time, as I mentioned at first, the 
majority of these cases fall victims to phthisis. On the other 
hand, by early excision the disease is cut short, the wound has 
healed in a week or two, and a useful movable joint is obtained. 
The objections to excision are the danger of the operation, the 
shortening of the arm, and the risk of a flail joint. The danger 
of the operation is very slight if the skin was unbroken before- 
hand, and this need only influence us where the patient has 
advanced phthisis, or is old and weak. The shortening is slight, 
unless when done in childhood, where, of course, in accordance 
with what I have previously said, I should consider it to be 
contra-indicated. As to the risk of a flail joint, I think that is 
not great, if one takes care not to injure the muscles unneces- 
sarily, and especially to peel off the periosteum at the muscular 
attachments, where it and the subjacent bone are healthy. It 
seems to me that, in suitable cases, it is surely preferable to 
excise the joint early, and thus get a rapid cure with a useful 
joint, rather than persevere for an indefinite time with rest, 
&c, with the ultimate result, after many months or years, of a 
stiff joint, and often in spite of the utmost care, with much 
impaired usefulness, not only of the shoulder, but of the elbow 
and hand, and a great risk of death from phthisis. 

As regards the operation of excision, I do not see any reason 
for departing from the usual method of a long anterior incision, 
except in so far that after the ends of the bones have been 
removed, the whole of the synovial membrane should be care- 
fully dissected away. 



CHAPTER XX. 

DISEASE OF THE ELBOW JOINT. 

Disease of the elbow-joint occupies the fifth or sixth place in 
order of frequency, comprising in my statistics 7'9 per cent, of 
the whole cases, and in the larger collected statistics 6 '3 per 
cent. It occurs mainly in young adults, at an earlier age than 
disease of the shoulder-joint. Most of the cases commence 
before twenty (66 per cent.), but after ten years of age. In 
my statistics one-third of the cases commenced before ten. 

In this joint the disease seems to be much more frequently 
primarily osseous than synovial, and the olecranon is the part 
most often attacked. Thus Konig found in 62 cases operated on 
that the disease was purely synovial in 10 and osseous in 42. 
Of these 42 cases the ulna, more especially the olecranon, was 
the primary seat in 22, the humerus in 17, humerus and ulna 
together in 2, and the radius in 1. Middeldorpf found in 137 
cases that the disease was primarily synovial in 30 and osseous 
in 107. Of the bones the ulna was attacked primarily in 49, 
the humerus in 33, the external condyle in 12, the internal 
condyle in 4, the humerus and ulna together in 18, the radius in 
3, the humerus, radius, and ulna in 2, and the radius and ulna 
in 2. The synovial form was most frequent below fourteen 
years of age, the proportion between synovial disease and bone 
disease at that period of life being 29'5 to 70'5. The disease, 
whether synovial or osseous, commences most often on the outer 
side of the joint. 

The elbow is one of the joints where we should especially be 
on the watch for the early beginnings of the disease, which are 
often localised either in the bone or the synovial membrane. 
Of the bones the most likely place is the olecranon. Disease of 



PATHOLOGY. 



311 



the olecranon will be indicated by enlargement of that bone, 
and if the deposit has reached the surface outside the joint, 
there is a painful spot, with bogginess and subsequently an 
abscess, in addition to the thickening. Another place where a 
localised bone deposit should be looked for is in the external 
condyle of the humerus. Localised synovial deposits are not so 
common, but I have seen them on the outer side of the joint 
about the head of the radius. 

The course of these localised deposits is the same here as else- 
where. When the deposit in the bone reaches the surface, it 




Fig. 47. — Disease of the right elbow joint. 

leads to the formation of an abscess over it, and not uncom- 
monly, in the case of the olecranon, infects the bursa. Where 
it reaches the joint, it causes the typical joint disease, either 
thickening of the synovial membrane spreading from the point, 
or sudden infection of the whole surface with great pain and 
suppuration in the joint, 

Leaving these local deposits, we may now consider the 
symptoms where the synovial membrane is diffusely affected, 



312 DISEASE OF THE ELBOW JOINT. 

whether primarily or by extension, from a local bone or synovial 
deposit. In the early stage of primary. synovial disease there is 
very little pain, and the joint moves with considerable freedom. 
The thickening of the synovial membrane is apparent in the 
hollows on each side of the olecranon, which are filled up, 
especially on the outer side ; the tip of the olecranon is also 
more indistinct on account of the filling up of the olecranon 
fossa (see Fig. 47.) As time goes on, this swelling on each 
side of the olecranon, which was at first in the form of ridges, 
becomes more diffuse, and we have a uniform enlargement in 
the region of the elbow-joint, which is more marked at this 
period, seeing that the muscles of the upper and forearm 
are undergoing atrophy. As the cartilage becomes destroyed, 
pain is complained of, and the joint becomes fixed by muscular 
action, in the first instance, in the characteristic position, viz. — 
about an angle of 125° to 140°, and more or less completely 
pronated. In the third stage, we have the formation of abscesses 
around the joint, which generally point and leave sinuses around 
the posterior and outer side. 

Where the case is one of primary bone deposit, which has 
communicated with the joint, we have in the early stage the 
localised thickening of the part with some indefinite aching, 
followed by symptoms of involvement of the joint, viz. — early 
rigidity, great pain on moving or jarring the part, but no marked 
swelling in the first instance. The further symptoms of the 
disease are similar to those just described. 

The ultimate result without treatment, if recovery takes 
place, is anchylosis in the position just described, a position 
which is most inconvenient, and which interferes greatly with 
the utility of the limb. 

Treatment. 

The elbow-joint is one where we can occasionally save the 
joint by early operation in cases where the disease is distinctly 



ARTHRECTOMY. 313 

localised at first. This is more especially the case where the 
deposit is present in the olecranon, or, as in one case on which 
I operated successfully, in one of the condyles of the humerus, 
and in that where there was a localised thickening in the 
synovial membrane in the neighbourhood of the head of the 
radius. It is unnecessary to do more than mention the fact. 

Where expectant treatment is to be employed the joint 
should be fixed at a right angle with the forearm midway be- 
tween pronation and supination. The most satisfactory arrange- 
ment is a silicate case ; splints do not keep the forearm in the 
proper position as regards rotation. The case should extend as 
high up the tipper arm as possible and down to the wrist, in 
fact, it is best to fix the wrist-joint : of splints the best is a 
posterior wire splint, coming well round the sides of the arm. 
I do not think that either extension or counter irritation are of 
much value in disease of the elbow-joint, the former not being 
easily managed, and, as regards the latter, the joint being 
too superficial. 

The operative measures, apart from the partial operations just 
referred to, are arthrectomy in children and excision in adults, 
and both yield very satisfactory results. As regards arthrec- 
tomy, T should advise its performance at a comparatively early 
period of the disease when the whole joint has become affected, 
and when there is no improvement on a fair but not prolonged 
trial of absolute rest, or when it is evident that if recovery 
takes place the joint will be stiff. By means of complete 
arthrectomy the disease is got rid of, and even without much 
passive motion an excellent result as regards movement is 
obtained. Arthrectomy is best performed by means of lateral 
incisions, one on each side of the joint. These incisions are 
carried down to the capsule, care being taken on the inner side 
to look for, isolate, and pull forward the ulnar nerve, and on the 
outer side in separating the capsule not to go too low and injure 
the posterior interosseous nerve. Having exposed the cap- 
sule on each side the triceps is lifted up, and the mass of 



314 DISEASE OF THE ELBOW JOINT. 

synovial membrane over the olecranon fossa isolated, and the 
same is done on each side of the olecranon and over the head of 
the radius. The joint is then opened and the posterior synovial 
membrane cut away. After detaching the muscles from the 
condyles and dividing the lateral ligaments one can now define 
the surface of the anterior capsule, and by means of the finger 
can lift off the various structures in front of it. Having in this 
way isolated the capsule it is cut off above and below where it 
joins the bone. It is while clearing the capsule on the outer 
side that one has to be especially careful of the posterior inter- 
osseous nerve. The joint is now quite loose and it is easy to 
protrude the ends of the various bones through either incision, 
remove all remains of synovial membrane, and investigate the 
surface of the cartilage and the ends of the bone. The bones 
are now replaced, the wound stitched up and the usual dressings 
applied. Passive motion should be begun in about ten days or 
when the wounds have healed, and kept up as long as is 
necessary. It may be mentioned, however, that in a number of 
cases an excellent functional result has been obtained without 
employing any passive motion. Some surgeons saw across the 
olecranon and wire it afterwards, but I have never seen any 
difficulty in thoroughly clearing the joint by the method I have 
described. 

In adults, I believe comparatively early excision is the better 
practice. Much depends on the occupation. No doubt the 
arm left after anchylosis without excision is the stronger arm, 
and for some employments movement is not so important as 
strength. Further, the length of time for which the patient 
is incapacitated must be considered, excision when properly 
performed, that is combined with complete removal of the 
disease, putting a stop to the trouble at once, and only laying 
the patient aside for a few weeks. I have more than once per- 
formed arthrectomy in adults, but I do not think the results 
are so good as those of complete excision. The best incisions for 
excision are lateral ones, as already described with regard to 



EXCISION. 315 

arthrectomy, and the capsule must be freed in a similar manner. 
If the back of the olecranon is healthy, the periosteum with the 
attachment of the triceps may be peeled off behind and left 
attached to the periosteum of the healthy bone below. The 
bones are sawn off in the usual manner. Passive motion should 
be begun in a few days, and a good plan is to put on exten- 
sion at night to straighten the arm, and an elastic band during 
the day to bend it. 

Where sinuses are present arthrectomy or excision should be 
performed, as the chances of recovery without operation are 
small and the treatment is very prolonged. Especial care must 
be taken in these cases to remove all traces of synovial mem- 
brane, and also, of course, to purify the wounds. 

Amputation is hardly ever required in elbow-joint disease, 
unless the case has been neglected or the disease allowed to go 
on too far. 

The functional results of excision depend very much on the 
method of operating, the amount of bone affected, and the after 
treatment, and hence opinions vary very much with regard to it. 
Perhaps a fair estimate is that given by Middeldorpf, who, 
taking Maas's and Giebe's cases together, found that good joints, 
flail joints, and stiff joints resulted after excision in the per- 
centage proportions of 75, 12J, 12J. 



CHAPTEK XXI. 

DISEASE OF THE WKIST JOINT. 

Disease of the wrist-joint, like that of the shoulder, is a disease 
of adults, commencing most frequently during the third decade, 
and it forms about 5 per cent, of the total cases of tubercular 
bone and joint disease. It is, I think, most often primarily 
synovial, but this is a very difficult point to determine on 
account of the number and small size of the bones. Primary 
osseous deposits occur in the lower end of the radius, and also 
in the ends of the metacarpal bones, chiefly the second and 
third. I have only seen two specimens of primary deposit in a 
carpal bone, in both cases in the trapezium. 

The course of the disease is similar to that in other cases, and 
need not be specially described. It begins with thickening 
around the joint, passing on to softening of the ligaments with 
lateral mobility, destruction of the cartilages with much pain, 
and ultimate suppuration and anchylosis. It is especially apt 
to be accompanied by phthisis. 

The thickening frequently begins, and is most marked on the 
outer and posterior aspect of the joint, corresponding with the 
most frequent commencement of the disease in that region, and 
it usually causes the appearance of a marked projection on the 
back of the wrist. The lateral mobility of the wrist, obtained 
by fixing the forearm and then grasping the wrist, displacing it 
laterally, is pathognomonic of tubercular disease. 

The characteristic appearance of the hand in cases which have 
not been treated, is that the hand and fingers are held straight 
out or slightly flexed, the fingers and thumb side by side, there is 
a marked swelling on the back of the wrist, and all around as well 
(see Fig. 48), and sometimes partial dislocation of the carpus back- 



SYMPTOMS. 



317 



wards. This is a very bad position, because, apart from adhesions 
in the tendon sheaths, which are very apt to occur, and interfere 
with the movement of the fingers, the usefulness of the hand is 
much impaired. Even with a healthy joint, if the wrist and 
fingers are placed in the same line with the forearm, the grasp 
is weaker, and where disease is present, the muscles wasted, and 
the action of the tendons interfered with, it is usually impossible 
to shut the fist at all with the hand in this position. Further, 
the opposition of the fingers and thumb is also lost where the 
thumb is kept constantly applied to the fingers. 




Fig. 48. — Disease of the carpus. 

Where the cartilages are becoming eroded there is great pain, 
and, the ligaments being also softened, the patient is unable to 
lift the hand, but supports it with the other. Further, in 
addition to the wasting of the muscles, the nutrition of the 
fingers is imperfect, they became tapering, glistening, and 
somewhat purplish. When suppuration occurs the sinuses are 
generally formed on the back of the wrist. It is also not very 
uncommon in cases which have been allowed to go on too long, 
for the sheaths of the tendons to become affected, an occurrence 
which gravely complicates the treatment of the case. 



318 DISEASE OF THE WRIST JOINT. 

TREATMENT. 

In applying splints or other apparatus to keep the joint at 
rest, special attention must be paid to the position of the hand 
in accordance with what I have just said. The splints should 
stop at the knuckles so as to allow free movement of the fingers, 
and the best arrangement is, I think, silicate bandage, 
strengthened in front by the incorporation of a light metal 
band. This should bend back opposite the wrist, so as to throw 
the carpus and metacarpus backwards ; the metacarpus should 
form an angle of about 150" with the forearm. The forearm 
should be midway between pronation and supination, and it is, 
I think, well to carry the bandage above the elbow joint. These 
silicate bandages are of course renewed whenever necessary. 

As regards operative measures it is rarely that one meets 
with a case before the joint has become diffusely affected, and 
where it would be possible to cut short the disease by removing 
the primary focus. Of course, if such a case came under notice, 
that ought to be done, but usually we have to deal with 
diffuse disease, and our choice of operations lies between 
arthrotomy, excision, and amputation. Arthrectomy in diffuse 
disease is not possible, apart from removal of the carpus, or at any 
rate, a modified excision, and as the disease is essentially one of 
adult life, this matter is not so important. In children, how- 
ever, it might be possible, after removal of the carpal bones, to 
clean the other parts without further removal of bone. Although 
complete arthrectomy does not come much into play in acute 
disease, a good deal can be done in some cases by partial opera- 
tions, either partial arthrectomy or simple arthrotomy. The 
first essential for these partial operations is that there is 
no phthisis, and the second that the disease is not progressing 
rapidly, but rather that the condition remains in statu quo 
without improvement. In suitable cases I have seen distinct 
improvement as the result of free incisions into the wrist-joint, 
with or without removal of portions of the affected tissue, the 



EXCISION VERSUS AMPUTATION. 319 

wounds being left freely open and the joint drained. As I 
have previously explained in speaking of knee-joint disease, this 
method is not likely to effect much where the tubercular tissue 
is abundant and undergoing caseation, and where one finds 
yellowish cheesy points in the synovial membrane. As to the 
best place for the, incisions, one usually chooses the lines for 
Lister's excision of the wrist, in case excision should become 
necessary subsequently, but of course if there is any special part 
where the swelling is most marked, the incisions should be 
made there, care being naturally taken not to injure the tendons 
or the tendon sheaths, and thus not to incapacitate the fingers, 
or open a way for infection of the tendon sheaths. 

The decision between excision and amputation depends partly 
on the general condition and partly on the local state of the 
part. As regards the general condition, the presence of phthisis 
is of course the gravest complication. Where phthisis is well 
marked and operative interference is necessary, amputation 
is much better practice than excision, and it is remarkable 
what improvement in the condition of the lung often follows 
the removal of the hand. Where the lung trouble is not 
advanced, and the general condition otherwise good, one may 
perform excision in preference to amputation. Formerly, where 
the whole disease was not removed, and where discharging and 
often suppurating sinuses remained for months, amputation was 
almost imperative, but now-a-days, where the whole disease is 
thoroughly removed, and where proper antiseptic precautions 
are taken, healing occurs by first intention, and as the patient 
is not confined to bed, there is no particular advantage in 
amputation unless in bad cases. Another condition where 
amputation becomes necessary is where, in addition to disease 
of the joint, the tendon sheaths are affected, a very serious 
complication. In such cases where suppuration occurs amputa- 
tion is the best practice. 

As regards the methods of performing the operations, amputa- 
tion is most conveniently performed by the modified circular 



320 DISEASE OF THE WRIST JOINT. 

operation as low down in the forearm as possible. Excision 
may be done either by Lister's original operation or by 
Langenbeck's modification, preferably, I think, by Lister's 
method, which gives freer access. It is hardly possible in the 
case of the wrist-joint to remove the synovial membrane 
thoroughly, and it is well where any suspicious tissue is left 
to cauterise it thoroughly with the thermocautery, and to 
fill the wound with iodoform and glycerine. Afterwards the 
hand is put on the splint designed by Sir Joseph Lister with 
the view of throwing back the metacarpus, and passive and 
active movements of the fingers should be begun almost at once. 
It has been proposed to shorten the flexor tendons at the time 
of the operation, but this is hardly necessary if the knuckles 
project well backwards. A very good functional result is 
obtained by excision in most cases if proper care is taken in 
the after treatment with regard to the position of the meta- 
carpus and the movement of the fingers. 



CHAPTEE XXII. 

DISEASE OF SMALLER BONES. 

The parts already mentioned, with the addition of the spine, 
form about 83 per cent, of all cases of bone and joint tuber- 
culosis, leaving about 17 per cent, of cases in which other bones 
and joints are attached. I shall refer shortly to some of these. 

1. Fingers and Toes. — Tubercular disease occurs much more 
often in the fingers than in the toes, and may either begin in 
the joints or in the shaft of the bones. The disease in the 
joints has no special interest, resembling on a small scale in 
every respect the disease in the larger joints, aud the treatment 
is either expectant treatment or amputation, according to 
the circumstances. In the case of the thumb, however, the 
retention of any portion is so important that partial operations, 
excision, &c, may with advantage be employed. 

The shafts of the phalanges or the metacarpal bones are, 

however, often attacked, and the disease may begin either as 

an osteomyelitis or as a periostitis, most commonly the former. 

Tubercular osteomyelitis of the shaft of one of these bones in 

children usually gives rise to the typical appearance of strumous 

dactylitis or spina ventosa (see Fig. 49), where there is a fusiform 

swelling of the bone due, as shown in Fig. 22, to expansion of the 

interior of the bone with soft material, and also to new bony 

formation on the surface. This swelling is firm, not particularly 

painful or tender to the touch, single, or may affect more than 

one bone, and does not in a considerable number of cases end in 

suppuration. On the contrary, it is remarkable how often, if the 

affected finger is properly fixed and kept at rest, and the child 

placed under good hygienic conditions, the swelling subsides, 

and ultimately entirely disappears without leaving any trace 
21 



322 



DISEASE OF SMALLER BONES. 



behind. Sometimes, however, the epiphysial line become 
destroyed or ossified, and a shortened condition of the bon 
remains. In other cases the new tissue breaks down and pu 
forms and makes its way outwards, and we have at some par 
or other an abscess, from which a small hole leads to the interio 
of the bone. A very similar condition may occur in congenita 
syphilis, and the diagnosis may have to be made by the preseno 
or absence of other signs of syphilis or tubercle. 

The treatment of this condition is in the first instanc 
absolute rest and proper general treatment, and as I havi 
just remarked, in the majority of cases a cure is obtained 




Fig. 49. — Strumous dactylitis. 

Where suppuration has occurred the abscess should be opened 
the opening in the bone enlarged, and the interior scraped out 
This may have to be repeated more than once, but usually end; 
in cure. Amputation is, curiously enough, rarely necessary ii 
this condition. 

In adults tubercular periostitis is more common, or if thi 
medulla is primarily affected, it is often associated with thi 
necrotic form (see Fig. 21). In these the prognosis is not si 
favourable, and although some of the milder cases yield to rest 
&c, the disease is very apt to prove obstinate, and, in a gooc 
many instances, requires amputation. 

2. Ribs. — The ribs are comparatively frequently affected witl 
tubercular disease. Thus, in Billroth and Menzel's table o 



DISEASE OF THE RIBS. 323 

1996 cases of post-mortem examinations in cases of carious bone 
disease, the ribs occupy the sixth place in order of frequency, 
forming rather more than 6 per cent, of the cases. The ribs 
most usually affected are the fourth to the eighth, generally 
about their middle. Tubercular disease of the ribs is essentially 
an affection of adults, and seldom occurs in children, and it 
may occur either primarily in the rib or secondarily to disease 
in the "neighbourhood. The secondary disease occurs in the 
form of a periostitis, and may follow a spinal abscess which has 
passed forward along the intercostal space, and is pointing in 
the side, or a tubercular pleurisy especially where an incision 
has been made, or suppurating tubercular axillary glands ; it 
is not uncommonly associated with phthisis. Here, however, 
we have only to do with the cases where the disease begins in 
connection with the bone, and is not merely an extension from 
the neighbourhood. The disease, in this case, may commence 
either as a periostitis or as an osteomyelitis, most commonly as 
a periostitis. Beginning in the periosteum, the tubercular tissue 
causes a swelling on the surface of the bone, which presently 
breaks down in the centre, and forms an abscess. At the same 
time, the new tissue spreads into the bone along the Haversian 
canals, and causes erosion of the bone, and sometimes actual 
necrosis of fragments. Hence the bone becomes thinner than 
usual, and presents a worm-eaten appearance on the surface, while 
the parts in the neighbourhood are condensed ; this super- 
ficial erosion of the bone steadily progresses, till a more or less 
marked defect is formed, indeed, fracture not uncommonly 
takes place. Much more rarely the disease begins in the in- 
terior of the bone, expanding it, and giving rise, in a slight 
degree, to the appearance of spina ventosa, referred to in con- 
nection with the fingers. 

The early symptoms of tubercular disease of a rib are very 
indefinite, consisting, at the most, of some uneasiness, or per- 
haps a little catching pain on deep breathing or coughing, and 
sometimes a little tenderness on pressure. If the swelling is 



324 DISEASE OF SMALLER BONES. 

especially inside the rib, the pleura may be irritated, and there 
may be a little cough, pain, and other signs of slight pleurisy. 
Usually, however, the first thing that is noticed is a little swell- 
ing, which leads the patient to seek advice. This swelling is, 
in the first instance, small, rounded, and elastic, and later in- 
creases in size, fluctuates, and may alter its shape according to 
the situation. These abscesses usually spread to the skin, but 
they may, in the first instance, bulge the pleura inwards con- 
siderably, or even open into the cavity, or they may burrow 
beneath the muscles, and point at some distance from the seat 
of disease; in the case of disease at the posterior end of the 
rib, even pointing in the loin or running down in the sheath of 
the psoas muscle, and forming a typical psoas abscess. The 
disease not uncommonly affects more than one rib or part of 
a rib. 

The treatment of tubercular disease of a rib, once an abscess 
has formed, should be thorough, and if thorough, will lead to a 
speedy cure. The treatment consists of complete removal of 
the disease. This is usually readily done. In the first instance, 
the skin and muscles are reflected from over the abscess wall, 
and, without opening it (a T-shaped incision being generally 
necessary,) the abscess is thoroughly isolated up to its point of 
attachment to the rib. It is then cut away, a strong stream of 
weak sublimate solution playing over the part at the time, so 
as to wash away all the pus from the wound. The extent of 
the affected bone is then defined, the rib divided beyond it on 
each side, and the whole diseased part removed. There then 
remains a mass of tubercular tissue, corresponding with the 
deeper surface of the rib, which must be very thoroughly 
scraped away; this is easily done. The wound, having been 
well washed out, is now closed by stitches, no drainage tube 
being necessary. Healing occurs by first intention, and if a 
sufficient piece of bone has been removed, there is no recurrence. 
This is a much better method of treatment than the partial 
ones of opening and drainage ; of opening, scraping, and inject- 



DISEASE OF THE STERNUM. 325 

ing iodoform and glycerine; or of opening and applying the 
actual cautery to the bone, a method at one time a good deal 
employed abroad. 

3. Sternum. — This bone is not unfrequently the seat of 
tubercular disease. In post-mortem examinations in cases of 
advanced phthisis, it is not uncommon to find greyish or yellow 
deposits in the sternum, but apart from these nodules, which 
are in reality curiosities, the sternum may present similar 
changes to other bones, the disease commencing in the perios- 
teum or the interior. Superficial caries of the sternum, 
secondary to periosteal disease, or to a deposit in the bone, is 
often very extensive, especially on the posterior surface, where 
the abscess formed in connection with it spreads upwards and 
downwards behind the bone before it makes its way forwards 
between the ribs or upwards into the neck, and infects 
the periosteum and the surface of the bone along its course. 
Deposits in the bone are also not uncommon, leading either to 
necrosis of portions, or to the formation of a cavity containing 
soft caseous material. 

Tubercular disease of the sternum begins usually with a little 
aching in the bone, succeeding which is some swelling where the 
disease has begun in the interior or on the anterior surface of 
the bone. This is soon followed by the development of an 
abscess and all the signs of tubercular bone disease. Where the 
posterior surface is affected, in the first instance, the symptoms 
are most indefinite, and the disease cannot usually be diagnosed 
till an abscess points between the costal cartilages or above the 
sternum ; it is rarely that the abscess attains such a size behind 
the sternum as to cause pressure symptoms. The diagnosis of 
the first condition must be made in the ordinary manner from 
acute periostitis ; abscess unconnected with the bone, &c. 
Where the posterior surface is affected, and an abscess points 
between the costal cartilages, it may on superficial examination 
be mistaken for a localised empyema, but careful examination of 
the chest and of the bone will soon reveal the true condition. 



926 DISEASE OF SMALLER BONES. 

The treatment must be conducted on the ordinary lines, 
abscesses being opened and washed out, bone being chiselled and 
gouged away, &c. In some cases, especially of posterior disease, 
it may be necessary to remove a portion of the sternum, 
generally the manubrium. 

4. The Clavicle is rarely affected with tubercular disease. 
When it is attacked, it is usually at the acromial end. Not 
uncommonly the disease is an extension from the acromion 
process of the scapula. There may also be a periostitis of the 
shaft of the bone, and in a few instances there has been an 
osteomyelitis, with distension of the shaft, as in the other short 
long bones. 

There is nothing special as regards symptoms and treatment 
which calls for remark. The affected piece of bone should be 
gouged or chipped away. 

5. The Scapula, apart from the neck and glenoid cavity, is 
also very rarely affected with tubercular disease. When it is 
attacked, the acromion process is the most usual seat, and the 
disease spreads more readily towards the clavicle than towards 
the spine of the scapula. 

6. Flat Bones of the Skull. — Tuberculosis of the flat bones of 
the skull is a rare affection, but one which assumes importance 
from its situation. The following is a description of the disease 
taken from the few cases published, and two which I have 
myself observed : — 

The disease affects young adults, and generally commences 
with pain in the head of a dull aching character, and tenderness 
on pressure over the affected part. The pain is presently 
followed by the formation of a fluctuating or semi-fluctuating 
tumour, in fact a chronic abscess. In some cases, however, the 
first symptoms after the pain are those of pressure on the brain 
from the formation of a collection of pus between the dura 
mater and the skull, such as dulness, sleepiness, slowing of the 
pulse, vomiting, &c. After a time the abscess bursts or is 
opened, and on passing a probe, the bone is felt to be bare, soft, 



DISEASE OF THE SKULL. 327 

and breaking down under the instrument, and in most cases 
one or more small necrosed fragments are found. 

The bones affected are chiefly the frontal, especially in the 
neighbourhood of the orbital margin and the external angular 
process, and the parietal. I have also had one case where the 
upper part of the occipital was affected. The mastoid process 
of the temporal is, of course, very commonly diseased, but that 
I do not refer to here. 

As a rule, the affection only begins in one place at a time, 
but it not uncommonly appears afterwards in other parts of the 
same bone, or in other bones. The process is, no doubt, similar 
to that already described, and in most cases it commences in 
the diploe. Here the disease presents the two usual forms, viz. — 
the formation of a deposit, either consisting of cheesy material, 
or more usually containing one or more sequestra. These 
sequestra are generally small, about the size of a pea or bean, 
but they may be more extensive, and in one or two cases they 
have been as large as a five shilling piece. They generally 
involve the whole thickness of the skull, and the inner table 
may be more extensively involved than the outer. Apparently 
there is no rarefying osteitis in the neighbourhood. Where the 
inner table is affected, the dura mater is separated from the bone 
over a considerable area, the interval between it and the bone 
being filled with tubercular material, often undergoing caseation. 

As a rule in these cases, there are symptoms of tubercular 
disease in the other bones of the body, and apparently this 
affection only occurs in the course of very severe tubercular 
bone disease. It may be the first affection, but generally it only 
commences after other bones have become involved. It may also 
begin in several parts of the skull at the same time, and in these 
cases the prognosis is bad, and in them there is generally severe 
tuberculosis elsewhere. It frequently seems to bear some 
relation to injury, apart from cases of external wound or 
compound fracture where infection may have occurred directly 
from without. 



328 DISEASE OF SMALLER BONES. 

This disease must be carefully diagnosed from syphilis. The 
later clinical symptoms, more especially the formation of a 
chronic abscess, are different from those' of syphilis, but as a 
rule the case cannot be diagnosed till the abscess is opened. 
The character of the lesions in the bone, more especially of the 
necrosed fragment, is very different ; as a rule, in syphilis the 
surface of the bone is extremely irregular, and shows a large 
number of small holes surrounded by hard, dense bone. 
Generally the gumma spreads into the bone from the peri- 
osteum, and hollows out a sort of spiral in the bone ; in the 
skull this spiral is arranged like the mainspring of a watch, but 
in the long bones it is more like a corkscrew. The walls of 
these spiral channels are composed of dense, ivory-like tissue, 
and this gives rise to the great weight of the sequestra in 
syphilitic disease. In syphilis also the sequestra are generally 
much larger than in tuberculosis. The characters of the tuber- 
cular sequestra have already been fully described. 

As these cases are not recognised till an abscess has formed 
or has burst, the treatment is essentially operative. Where an 
abscess is present it must be opened freely after thorough dis- 
infection of the parts, and the condition of the bone examined. 
Where the disease seems to be entirely periosteal, it may be suf- 
ficient to chisel away a thin scale of the bare surface of the bone, 
remove the wall of the abscess, fill the cavity with iodoform 
and glycerine, and stitch up the wound. Where, however, the 
disease is situated in the medulla, and especially if sequestra 
are present, it is best to remove the affected part completely by 
means of a trephine, and investigate the condition of the inner 
table before closing the wound. Where sinuses are already 
present they must be thoroughly removed and the wound 
sponged with pure carbolic acid, the bone being dealt with in 
the manner just described. 

7. Mastoid process. — Tubercular disease of the mastoid process 
is very common in connection with disease of the ear, and leads 
to many complications, such as destruction of the middle ear, 



DISEASE OF FACIAL BONES. 329 

suppuration in the groove of the lateral sinus, abscess of the 
brain, meningitis, &c. These troubles are, however, accidents, 
due to the septic complications, and not to the presence of 
tubercle per se, and their consideration would lead us quite 
away from the objects of this book. The chief complication 
related to the tubercular nature of the disease is the occurrence 
of tubercular glands in the neck, which are very common, and 
where they exist, along with discharge from the middle ear, the 
mastoid antrum and process ought, I think, to be opened up 
without delay and the diseased bone removed and treated on 
the same lines as elsewhere. 

8. Bones of the face. — Tubercular disease of the bones of the 
face is more frequent than that of the flat bones of the skull, and 
the most common seat of the disease is about the orbital margin 
of the superior maxilla or the malar bone. There the disease 
usually commences in the periosteum, and leads both to caries 
of the bone and to ulceration of the skin, and the latter con- 
dition is usually followed by serious ectropion. The lower jaw is 
also sometimes, but not so frequently, attacked, and in it the 
disease usually begins about the angle, and leads to swelling 
and abscess formation, the abscess bursting externally over or 
beneath the jaw, or sometimes into the mouth. 1 need not 
enter into any special description of the symptoms or treatment 
of these affections, as they coincide in all respects with the 
symptoms and treatment elsewhere. 

In some cases of scrofulous ozsena the tubercular disease has 
attacked the bones of the nose, either primarily or secondarily 
to disease of the mucous membrane over them. Where 
sequestra are present, we generally have to do with primary 
tubercular disease of the bone. Over the affected parts the 
mucous membrane becomes ulcerated, or a large granulation 
mass is formed, which may fill up the nasal cavity. These 
cases must be treated by free scraping away of the diseased 
tissue, and subsequent cauterisation repeated on any appearance 
of fresh disease. 



CHAPTEK XXIII. 

DISEASE OF THE SPINAL COLUMN. 

Tubercular disease of the vertebrae is the most common tuberr 
cular bone affection in children, occupying in my lists from 40 
to 46 per cent, of the whole, and, taking all ages together, it 
still remains at the head of the list. Thus in Billroth and 
Menzel's table, to which I have previously alluded, the vertebrae 
were the seat of disease in 23 per cent, of the cases. As to the 
age at which it begins it has been found by most authors that 
at least 50 per cent, of the total cases commence before ten 
years of age ; Drachmann indeed gives the proportion as 77 per 
cent. Some authors, Miiller for example, assert that tubercular 
disease of the vertebrae does not occur under three years of age, 
and that cases so diagnosed earlier are in reality either syphi- 
litic or rickety. This, however, is not the case. Jaffe was able 
to make a post-mortem examination on a case which com- 
menced when the child was eight weeks old, and which was 
undoubtedly tubercular. In my own list of in-patients one com- 
menced at three months, and three others during the first year of 
life, and these were shown to be tubercular by the occurrence 
of psoas abscess and by post-mortem examination in one in- 
stance. I also possess the cervical vertebrae from a child 
a ged 1£ years, parts of which have been destroyed by tuber- 
cular disease. Among my out-patient cases I had 4 which 
were only a few months old when they came under observa- 
tion, 3 were a year old, 8 were 2 years old, &c. The explana- 
tion of the greater frequency of disease of the vertebrae, as 
compared with other bones, is no doubt in part at least that 
there are so many vertebrae, but apparently also they are 
especially predisposed. 



PATHOLOGY OF SPINAL DISEASE. 331 

The favourite seat of the disease is the dorsal vertebrae, 
chiefly the middle and lower ones, then the upper lumbar, 
and then the cervical, especially the upper cervical. This is, 
however, variously stated by different authors, some stating 
that the first lumbar is the one most frequently affected, others 
giving the sixth and seventh cervical, others the sixth and seventh 
dorsal. I think that my statement meets the facts of the case. 
The disease may commence in the interior of the bone or on 
the surface. Commencing in the interior it presents the usual 
two forms, viz. — soft deposits or sequestra; on the surface it 
either begins in the periosteum or very soon involves it, and 
spreads along the surface of the vertebrae causing a more or less 
extensive superficial caries. The deposits in the interior of the 
bone usually commence near the intervertebral cartilages, and 
rarely affect more than two or three vertebrae. They generally 
make their way to the surface on the front or sides of the 
vertebras, and then spread over the surface causing a superficial 
caries. They also spread towards the intervertebral cartilages 
and destroy them either in part or completely. In rarer cases 
they extend backwards and reach the surface at the posterior 
part of the body of the vertebrae. When these deposits reach 
the surface they often lead to the formation of an abscess 
either at the sides of the vertebral column, or, where they 
extend backwards, in the spinal canal itself. These deposits in 
the bone destroy the body of the vertebra in which they occur 
more or less completely, the weight of the body causes the 
vertebra above to sink down, and more or less acute curvature 
results. Where a single body only is destroyed the curvature 
is quite angular. Not uncommonly, however, two or three 
bodies are simultaneously attacked, the result being that the 
curvature is not so abrupt and involves three or more vertebra;. 
The most common arrangement is that one or two bodies are 
more or less completely destroyed as the result of primary 
deposits in their substance, and that secondarily to that, and 
as a consequence of periosteal extension, the intervertebral 



332 DISEASE OF THE SPINAL COLUMN. 

cartilages of several adjacent vertebrae disappear, and thus 
there is a gradual curve affecting several vertebrae with, in 
the centre, a more acute curve due to the destruction of one 
or more bodies. Where superficial caries of the vertebrae 
occurs it is either the primary disease, or is secondary to a 
deposit in the vertebrae which has reached the surface. In 
whichever way it arises the disease spreads along the surface 
and generally extends over a considerable number of vertebrae. 
When it reaches the intervertebral cartilages it spreads inwards 
along them and destroys them. This leads to a gradual curva- 
ture of the spine, which is increased by absorption of the upper 
and lower surfaces of the bodies to some extent, and conse- 
quently there is an extensive and gradual curve. This form occurs 
more especially in adults, is most often associated with abscess, 
and, if it alone is present, there may be no curvature, or in the 
first instance only a gradual bend due simply to the loss of a 
number of intervertebral cartilages. On the other hand, the 
deposits in the interior of the bones are less frequently asso- 
ciated with abscesses, occur chiefly in children, and are accom- 
panied by acute curvature, and the other displacements (such as 
lateral) which are sometimes present. 

In some rare cases the disease affects the transverse or spinous 
processes primarily, and then it usually commences as a super- 
ficial caries, quickly followed by abscess. 

In the case of disease of the vertebrae, the destructive processes 
are to a large extent due to inflammation and absorption of the 
inflamed bone. The inflammation is set up, in the first instance, 
of course, by the tubercular disease, and it is kept up by 
pressure, and the absorption is mainly due to pressure. This 
pressure is partly caused by the weight of the head and upper 
part of the spinal column, especially the bending of the upper 
part of the body forwards, and partly by the contraction of the 
muscles surrounding the spine keeping the inflamed parts in 
constant and firm contact. I regard the last point as one of 
very great importance, and it is one which is not generally 



SYMPTOMS OF SPINAL DISEASE. 333 

understood or regarded. I have already pointed out the 
importance of muscular contraction in hip-joint disease, and my 
remarks apply with still greater force to the spine. 

Symptoms. 

In discussing the symptoms and signs of spinal disease we 
have to note differences, according to the situation of the 
affection, but I may in the first instance sketch a case, say, in 
the dorsal region, and then subsequently refer to the chief 
points in detail. In the early stage the patient has a sense of 
uneasiness and aching in his back, especially after he has been 
up for some time, which is relieved by lying down. Sometimes 
at this stage there may be neuralgic pains shooting along the 
ribs or even down the limbs, but this is not so common in 
dorsal disease as in cervical or lumbar disease, and in any case 
it is not very common as an early symptom. By-and-bye the 
aching pain in the back becomes more marked, especially on 
running, jumping, going down stairs, &c, and the child ceases 
playing and is always wanting to sit or lie down. Examination 
of the back at this time does not usually show curvature, but 
distinct rigidity can be made out, neither bending forwards nor 
backwards being properly carried out ; pain will also be induced 
by pressure on the head or shoulders, and by pressure over the 
transverse processes on each side of the spine. As time goes on 
the back becomes more prominent at the seat of disease, and 
by-and-bye a distinct curvature develops. At this stage the 
pain becomes more marked, and when the child is asked to pick 
up anything from the floor he does not stoop but bends his 
knees, . and often in rising again he supports his trunk by 
placing his hands on his thighs. If the case is neglected the 
curvature increases, and very often symptoms of paralysis 
supervene, commencing with pains around the waist, abnormal 
sensations in the limbs, and ending ultimately in complete 
paraplegia. At the same time abscess, usually psoas or lumbar, 



334 DISEASE OF THE SPINAL COLUMN. 

appears, and by-and-bye bursts and leaves a discharging sinus. 
Ultimately the patient dies of exhaustion from the prolonged 
discharge, of phthisis, of tubercular meningitis, &c. Such is 
the very common history of a case where no treatment has 
been adopted, but the symptoms do not always follow this 
course ; sometimes the presence of an abscess is the first in- 
dication of anything wrong, at other times a curvature may 
already be found when the patient first complains, &c. 

I may now refer more in detail to some of the chief symptoms. 

1. Pain. — This is a constant symptom of active disease of the 
bodies of the vertebrae. The pain is of a dull, aching or gnawing 
character, and is increased by movement, running, jolting, 
jumping, going down stairs, &c, and is always worse towards 
evening if the patient has been going about during the day. 
The aching goes on for a considerable time, even after the 
patient lies down, but generally towards morning he feels 
pretty comfortable, unless the disease is progressing very 
actively. The pain is greater where the substance of the bodies 
of the vertebras is affected than where there is only caries of 
the surface. In addition to pain at the seat of disease, there 
may be even at an early period pain of a neuralgic character 
radiating from it. These early pains are frequently looked 
on as rheumatic, and may be quite of a fugitive character ; in 
other cases they are more definite, consisting in dorsal disease 
of a feeling of weight and constriction around the chest, in 
lumbar disease of pain along the sciatic nerve, &c. When 
these symptoms are bilateral, there is generally actual pressure 
on the cord, but the earlier fugitive pains have been referred to 
neuritis from pressure on the nerves outside the canal by the 
tubercular material. These early neuralgic pains are apparently 
most frequent in cervical disease. 

In investigating the existence of pain, all actions which 
produce pressure on or movement of the affected vertebra 
should be tried. Pressure on the head or on the shoulders, if 
the disease is situated in the dorsal or lumbar regions, will at 



SYMPTOMS OF SPINAL DISEASE. 335 

once produce pain at the seat of disease. Similarly, stooping, 
lateral, and rotatory movements also cause pain. The 
favourite method of examination is to tap the spines of the 
vertebrae, when pain will be experienced over the seat of 
disease. This is not, however, a very satisfactory method, 
because if the tapping is roughly done, or the skin thin and 
sensitive, the pressure of the skin against the spines causes 
pain at that part, while on the other hand, where there is 
only superficial caries, pain may not be elicited. A much 
more delicate test is obtained by pressure on the transverse 
processes. By pressure on the transverse processes rotation 
of the bodies is caused, and pain is at once produced, even 
when the disease is not extensive, and as these processes 
lie deeply, the fallacy of pain from pressure of the skin 
against the bony points is got rid of. This method of 
examination is specially valuable in cases of hysteria where, 
while pressure on the spines generally elicits the complaint of 
pain, the patients do not exhibit a similar result from pressure 
further to the side, and besides, the skin, which is frequently 
hyper-sensitive, is not pressed against sharp bone. 

2. Rigidity.— -One of the earliest symptoms of tubercular 
disease of the spine is rigidity of the affected part. The 
muscles surrounding the affected vertebra pass into a state of 
tonic contraction, and iix that part of the spine more or less 
completely. Hence, on causing the patient to move his spine 
in various directions, the affected part is kept rigid, and the 
movements are imperfectly performed. Thus, if the part affected 
is the dorso-lumbar region, and the patient is told to pick up 
something from the ground he does not stoop to do so but 
bends his knees till his hands can reach the ground. Similarly, 
where the upper cervical vertebra? are affected (especially in 
atloaxoid disease), the rotation of the head on the spine does 
not occur, but if the patient is told to look to one side he 
rotates his trunk, or if to nod the flexion occurs in the dorsal 
region. This early rigidity is a most important diagnostic 



336 DISEASE OF THE SPINAL COLUMN. , ' 

point, especially in distinguishing the disease from hysterical 
affections. In the latter case, although the pain complained of 
may be excessive, this rigidity of the spine is usually absent. 

3. Deformity. — The amount of deformity in spinal disease 
depends on the parts of the bodies which are affected. Where 
there is superficial caries of the vertebrae there is, in the first 
instance, no deformity, but by-and-bye, as the intervertebral 
cartilages are destroyed, the back becomes, in the first 
instance, flattened (where there is naturally a curve forwards), 
and ultimately a certain amount of antero-posterior curvature 
is produced. As a rule, in this form of disease a number of 
vertebras and intervertebral cartilages are involved, and hence 
the curve is not acute, but is rather a gradual bend backwards, 
and it is not usually very marked. Where the disease has 
commenced in the form of a deposit in one or more vertebras 
the curvature is much more marked and acute, from the more 
or less complete destruction of one or several bodies. Here, as 
a rule, the curvature is not nearly so extensive as in the former 
case, but it is much more abrupt. It may occur suddenly or 
gradually, is always antero-posterior, but may also, in some 
cases, be somewhat lateral. This last condition is produced 
where one side of the body has been more destroyed than the 
other, or where the body has been completely cut across, and 
where generally, as the result of some sudden movement, the 
upper portion has slipped to one side. This is really a partial 
lateral dislocation, but true lateral curvature may also, though 
rarely, be associated with the antero-posterior. The chief cause of 
the rapid development of the antero-posterior curvature is the 
erect posture, the weight of the upper part of the spine crushing 
together the soft bone, but it may also occur more gradually 
where the patient is kept in bed in the recumbent posture, but 
without any extension apparatus. In the latter case it results 
from the tonic contraction of the muscles surrounding the spine 
gradually pulling the vertebrae together as the diseased parts 
become absorbed. 



SEATS OF SPINAL ABSCESS. 337 

4. Abscess. — As in tubercular disease elsewhere, the formation 
of a chronic abscess is a frequent accompaniment of tubercular 
disease of the spine. It is most frequent in cases of superficial 
caries, the disease naturally extending readily to the soft parts 
as well as to the bone, and it also occurs earlier in these cases. 
Hence in adults, where this form of disease is most common, 
abscess is more frequent than in children, where we most 
commonly meet with deposits in the substance of the bodies 
and acute curvature. These abscesses form in front, or at the 
sides, of the bodies, and point in various places according to the 
region affected. In the upper cervical region they most usually 
form in front of the vertebra?, giving rise to the retro-pharyngeal 
abscess, which points in the pharynx or passes outwards on 
each side at the upper part of the anterior triangle ; in other 
cases they may extend backwards and point in the suboccipital 
region. At the lower part of the neck they usually appear in 
the lower part of the posterior triangle, or they may project the 
oesophagus and trachea forwards; they may also pass down 
into the posterior mediastinum, or into the axilla. In the 
dorsal region the abscesses form inside the thoracic cavity 
in front or at the sides of the vertebras, and they sometimes 
make their way backwards between the transverse processes, 
and project in the back, forming the dorsal abscesses. In other 
cases they extend forwards beneath the pleura, and pass out- 
wards about the middle of the side of the thorax, giving rise 
at first sight to the idea that the case is one of abscess in con- 
nection with a diseased rib ; this idea is often strengthened 
when, on opening the abscess, the rib is found to be bare, for 
the periosteum is very apt to become infected at the point 
where the abscesses have passed outwards; the diagnosis can, 
however, be made by the presence of other symptoms of spinal 
disease, and by finding that a sinus leads backwards towards 
the vertebrae. Abscesses in connection with the dorsal vertebras 
may also, though very rarely, extend into the posterior media- 
stinum, burst into the pleura, lung, &c. At the upper part of 
22 



338 



DISEASE OF THE SPINAL COLUMN. 



the dorsal region the abscesses not uncommonly pass upwards, 
and point in the lower part of the posterior triangle, and at 
the lower part of this region they most usually pass downwards 
through the pillars of the diaphragm, and along the sheath of 
the psoas muscle, forming typical psoas abscesses (Fig. 50). 
In the lumbar region they generally pass down in the 
sheath or substance of the psoas muscle as psoas abscesses, or 
they pass backwards and form lumbar abscesses. Where the 




Fig. 50. — Psoas abscess pointing at the upper and inner part of 
the left thigh, in connection with spinal disease. (After Bradford 
and Lovett.) 

lowest lumbar vertebrae are affected, they may form in the 
iliac fossa, and point above Poupart's ligament, at the outer 
part, as iliac abscesses ; or sometimes, though very rarely, they 
extend backwards through the sacro-sciatic notch, or through 
the obturator foramen, and point in the buttock or back of 
the thigh, or even in the perineum. 

5. Effect on the spinal cord. — The disease of the bodies of 
the vertebrae may not only extend forwards, but also backwards, 



PRESSURE ON THE SPINAL CORD. 339 

and, under certain circumstances, lead to prejudicial effects by 
pressure on the cord. This pressure originates in two ways. 
In the first and most common mode, the dura mater becomes 
infected and thickened, the condition of pachymeningitis being 
produced, and these thickened membranes fill up the spinal 
canal and press on the cord. In other rarer cases, an abscess 
forms beneath the dura mater, and causes it to bulge backwards 
and compress the cord against the laminae of the vertebras ; in 
this case the symptoms of pressure may suddenly subside when 
an abscess forms in front or is opened, the internal abscess com- 
municating with and emptying itself into the external. It is 
possible, also, that similar symptoms may arise in cases of very 
acute curvature from kinking of the cord and interference with 
the circulation. Formerly it was supposed that in an acute 
curvature the cord might be stretched over the bodies of the 
vertebras, and pressed upon in that way, but though it is pos- 
sible that a spicule of bone may press on the cord, pressure by 
the merely curved vertebras does not occur. As a matter of 
fact, however acute the curvature, the calibre of the spinal 
canal remains the same, so long as there is no pachymeningitis 
or abscess in it, and as it is actually shortened, the cord lies 
quite loosely in it, and is not stretched over the anterior wall 
of bone, but, if pressed on, it is by the mass of granulation 
tissue which is present behind the bone. This is a very 
important fact to remember from the point of view of treat- 
ment. This pachymeningitis is greatest at the anterior surface, 
and seldom surrounds and constricts the cord, and, in the first 
instance, it is generally non-tubercular. As a result, myelitis 
occurs at the seat of compression, and there the cord may be 
flattened, softened, and, in some cases, almost diffluent ; second- 
ary degenerations spread from this point. The spinal nerves 
may also be pressed on and undergo alterations, as the result 
of the new growth of granulation tissue in the neighbourhood. 

The symptoms which arise from this condition differ, of 
course, according to the part of the cord pressed upon, but they 



340 DISEASE OF THE SPINAL COLUMN. 

all consist of the effects of pressure, leading to paralysis of the 
parts beneath. Prior to paralysis, various trophic changes may 
occur from this inflammation of the cord and nerves, such as 
wasting of the muscles, dry scaly skin, local sweating, vasomotor 
disturbances, such as oedema, coldness, &c. As a rule, -paralysis 
of motion is the first to occur, and may be complete as regards 
the lower extremities, and in certain cases as regards the rectum 
and bladder. Sensation is very seldom lost, and if impaired, 
is the first to recover. The paresis is, in the first instance, 
slight, and may remain so, but usually after some time spasms, 
and subsequently contractures, occur, accompanied by atrophy 
of the muscles. The reflexes are exaggerated, and ankle clonus 
is present at this stage. If sensation is affected, tactile anaes- 
thesia generally appears first, and analgesia last. Other modi- 
fications of sensation, especially retarded perception, may also 
occur. Want of co-ordination of movements may be observed. 
The nutrition of the affected limbs is also profoundly affected. 

The symptoms and signs of spinal disease vary according to 
the region affected, and I may, in a few words, refer to the chief 
points, with especial reference to the pressure effects on the 
cord. 

(a.) Disease at the tipper part of the cervical region. — Here the 
disease generally begins, and is most advanced in the atloaxoid 
articulations, and the odontoid process of the axis is very fre- 
quently affected. The main seat of the disease is in the articular 
surfaces, the cartilages of which become extensively destroyed, 
sometimes more on one side than on the other ; portions of the 
bones may become necrosed, especially the anterior arch of the 
atlas. There is a great tendency for the atlas to be displaced 
forwards on the axis. When recovery takes place, anchylosis 
is the result. 

In the early stage, the symptoms are, difficulty in moving the 
head, local pain, and pain radiating about the back of the head 
and following the course of the various upper cervical nerves. 
Pressure on the head or neck causes pain, nodding and rotation 



SYMPTOMS OF CERVICAL DISEASE. 



341 



are diminished or abolished, there may be a certain degree of wry- 
neck, and deformity in the suboccipital region, that fossa being 
filled up. The degree of pain varies, and, in many cases, becomes 
aggravated as the disease goes on, so that, after some months, 
the weight of the head becomes unbearable, and the patient 
supports the head with the hands, or remains lying : this con- 
dition may be somewhat relieved if an abscess forms, the head 
being then supported, so to speak, on a water pillow. At this 
period, also, displacements of the bones 
are apt to occur. 

At the same time, grave symptoms 
are apt to occur as the result of com- 
pression of the cord, either by the 
soft tissues or the displacement of the 
bones, especially by pressure of the 
odontoid process. Where displacement 
occurs suddenly, immediate death may 
result from crushing of the medulla, 
but this is very rare, and usually the 
pressure takes place more gradually, 
and death is preceded by paralytic 
symptoms. These begin as feebleness 
of the extremities, and often limited 
paralysis ; the arms are usually affected 
first. The lower extremities may be 
affected, and sometimes also the bladder 
and rectum, in the form of retention 
and constipation, though in some in- 
stances of incontinence. 
(b.) Cervical and cervico-dorsal disease. — In this region the stiff- 
ness of the neck is very apparent, and there may also be wry- 
neck, there is marked angular curvature, the neck is shortened, 
and the anterior part rounded (Fig. 51.) Where the upper dorsal 
region is also affected in children, there is deformity of the thorax, 
the ribs approaching each other, and running almost vertically 




Fig. 51. — Position of the 
head in disease of the 
cervical spine. (After 
Bradford and Lovett.) 



342 



DISEASE OF THE SPINAL COLUMN. 



downwards, and the antero-posterior diameter of the thorax is 
much reduced. Pain is also present in the region of the cervical 
or brachial plexus, according to the situation of the disease. 
As regards the effects on the cord, pressure effects are not so 
common here as in the lower dorsal region, and when they 
occur, the upper extremities are usually first attacked, but the 
lower limbs may subsequently become affected. The paralysis 




Fig. 52. — Disease in the mid-dorsal region with psoas' abscess. 

may be unilateral, or even confined to groups of muscles, and 
in this case it is due to alterations in the roots of the nerve 
trunks. Very often, also, there are pupillary changes, either 
myosis or mydriasis, and there may also, in rare instances, be 
other troubles, such as pulmonary, cardiac, or gastric disorders, 
in the form of cough, slow pulse, vomiting, &c. Where there 



SYMPTOMS OF DORSO-LUMBAR DISEASE. 343 



is complete paraplegia, there is often retention of urine and 
constipation. 

(c.) Dorsal and Dorso-Lumbar Disease. — After what has been 
already said it is unnecessary to go again' into the symptoms 
of the disease in this situation, and I need only remark that 
where the curvature is in the mid-dorsal region the thorax 
assumes a globular shape, the sternum being projected for- 
wards, and the antero- posterior diameter 
increased (see Fig. 52). Paralysis is most 
common in disease in the mid-dorsal 
region, and not nearly so frequent in 
lumbar disease. At an early stage there 
may be pains radiating down the limbs, 
and especially round the waist, as if a 
cord were tied round. Paraplegia may 
be complete or incomplete, the limbs are 
at first flaccid, but later there is con- 
tracture, reflexes are generally increased, 
and sensation diminished or it may be 
abolished. When the pressure is at the 
level of the lumbar enlargement, the 
limbs remain flaccid, the reflexes are 
feeble or abolished, and there is incon- 
tinence of urine and faeces. 

(d.) In lumbosacral disease the nervous 
troubles are due to neuritis, and hence 
the paralytic symptoms are limited to 
parts of the limb in the first instance, 
and are not necessarily bilateral or symmetrical, reflexes 
soon disappear, and faradic contractility of the muscles is 
lost. In disease in this situation in children the pelvis is 
apt to be deformed, becoming funnel-shaped. A somewhat 
similar deformity may result secondarily in dorso-lumbar 
disease. 




Fig. 53. — Dorso-lum- 
bar disease with iliac 



344 DISEASE OF THE SPINAL COLUMN. 

Diagnosis. 

In adults rheumatoid arthritis may attack the articulations 
of the spine, especially in the cervical region, and it may at 
first sight be somewhat difficult to distinguish it from tubercular 
disease, but in the former case the deviation of the neck is slight, 
or not at all present ; in the early stage the movements, although 
limited, can be carried out to a certain extent without violent 
pain, and are accompanied by creaking ; the swelling of the 
neck is hard, not soft, as in the tubercular condition ; the 
disease may last a long time without giving rise to marked 
deformity, and the general condition remains good. — The more 
acute joint affections, such as rheumatism, come on quickly 
instead of insidiously, attain their height in a few days, and 
then gradually subside. — A secondary malignant deposit in the 
body of a vertebra may give rise to a curvature, and has been 
mistaken for tubercular disease, but the history of the primary 
disease, the violent pain which precedes the deformity, the 
existence of other secondary deposits, &c, will prevent the possi- 
bility of error. — Hysterical spine is sometimes difficult to 
distinguish, but in that case rigidity is usually absent, and the 
tenderness is superficial and not increased by pressure on the 
transverse processes. — In the case of cervical disease the wry 
neck associated with it may be distinguished from the other 
forms by the tenderness of the sterno-mastoid or other muscles 
in the rheumatic form, and by the fact that in ordinary old 
standing wry-neck, the limitation of movement is only in that 
one direction, other movements being free. — In some cases of 
sprain it may be difficult, in the first instance, to be sure that 
the bone is not affected, but here there is a distinct history of 
injury, the tender parts are usually to one side of the spine, and 
there is no deformity. Sprain rarely occurs in children, but if 
it does the case should be watched carefully. — In rickets, 
curvature of the spine is not uncommon, but usually it is very 
extensive and forms one uniform curve, there is not so much 



TREATMENT. 345 

rigidity, and other signs of rickets are present. — Hip-joint 
disease is generally mentioned among the diseases to be 
excluded, and where psoas abscess is present, or contraction of 
the psoas muscle from irritation, the thigh is flexed, abducted, 
and rotated outwards ; the possibility of complete flexion and 
free movement in that position, show, however, that the case is 
not one of hip-joint disease. 



Treatment. 

As in the case of other bones and joints, the essential part of 
the treatment is to place the affected part absolutely at rest, and 
as far as possible to remove all sources of irritation. In order 
to place the spine completely at rest, it is necessary to prevent 
antero-posterior and lateral movements, to remove the weight 
of the upper part of the body, and to put a stop to the spasmo- 
dic contraction of the muscles. This can be brought ahout by 
placing the patient flat in the recumbent (supine) position on a 
pretty firm bed, without any pillow, laying heavy sandbags on 
each side from the axillae to the feet to prevent lateral move- 
ment, with sheets over the legs, pelvis, and thorax, passed under 
the bags to prevent antero-posterior motion, and extension 
applied to the head and feet to bring about muscular 
relaxation. 

Formerly it was the fashion to place the patient in the prone 
position, and even now this is advocated by some. The advan- 
tages claimed are that the patient is able to read, play, eat, &c, 
much more comfortably than when lying on the back, and that 
there is no direct pressure on the prominent spine, and it is said 
to restrain the action of the abdominal muscles from raising the 
spine. The prone position is in my opinion essentially bad, 
because it does not give the spine absolute rest; because it 
cannot be satisfactorily combined with extension ; because the 
thorax and abdomen are pressed upon, and there is consequent 



346 DISEASE OF THE SPINAL COLUMN. 

interference with the functions of the contained organs ; because 
there is pressure on the front or diseased part of the spine ; and 
because the bowels and bladder cannot be relieved satisfactorily 
without movement. The bed should be a hair mattress on the 
strongest canvas stretched over the best spring mattress ; if the 
mattress is too soft, or the springs too weak, the body sinks in 
the middle, and the upper and lower part of the spine are 
pressed together. For the same reason there ought to be no 
pillow or bolster, but the head should lie fiat in a line with the 
body, and should not be raised for any purpose, unless, indeed, 
the disease is in the lower lumbar region, when, so long as the 
shoulders are not moved, the head may be left free. A point 
which is not sufficiently attended to is the use of the bed-pan. 
In introducing it, the patient is rolled round or raised, and this, 
of course, entails movement of the spine. The best arrangement 
is to have the mattress made in three transverse pieces of 
different sizes, the narrowest being opposite the pelvis, and 
slightly broader than the bed-pan. This narrow piece is again 
divided into two in the middle, and when the pan is to be used, 
one-half is pulled out, the bed-pan slipped in, and the other 
side drawn slightly out, so as to let the bed-pan get into posi- 
tion ; in this way the back is not moved, and during defsecation 
the pelvis rests partly on one-half of the mattress and partly on 
the bed-pan. 

The thighs must be kept down as well as the body, because 
drawing up of the thighs means the action of the psoas, and 
consequently disturbance of the seat of disease. In cervical 
disease the head and neck must be placed between fat short 
sandbags. In very restless patients, especially in cervical 
disease, it may be necessary to mould a light plaster of Paris 
casing over the front and sides of the patient, so as to control 
movement efficiently, but usually the sandbags are enough. 

The application of extension to the head and lower extremities 
is one of the most valuable points in the treatment of spinal 
disease at all stages. It is applied as follows : — The ordinary 



DOUBLE EXTENSION IN SPINAL DISEASE. 347 

extension arrangement is attached to each thigh, and a weight 
of about 3 lbs. to begin with in children is affixed to each, the 
thighs being somewhat abducted. A similar weight is attached 
to the head by means of a chin and occipital band meeting 
above the ears, and continued up to a pulley at the head of the 
bed. As a rule, 3 lbs. is as much as can be comfortably borne 
at the head, but in adults a little more may be put on the 
extremities. It is not, however, necessary or desirable to have 
very great extension, because when long continued, even a slight 
weight is sufficient to tire out the muscles. The movements of 
the patient must, of course, be also controlled in the manner 
already described. 

The combination of double extension, with absolute fixation 
of the spine, is in my opinion the ideal treatment of spinal 
disease during the progressive stage and in any situation, and a 
few months' treatment in this way will do as much and more for 
a case than very prolonged treatment with the various forms of 
spinal supports. At first sight one might think that the general 
health would suffer from confinement in bed, but the contrary is 
the case. The immediate cessation of the inflammatory process, 
pain, &c, leads to improvement in health, appetite, and general 
condition, and if the patient is kept under good sanitary condi- 
tions, the general health will not suffer for a long time ; the 
cases where improvement in these respects does not follow con- 
finement to bed are in most cases those in which no efficient 
rest is given to the affected part. I have known cases of psoas 
abscess kept in bed and at rest for a long time, even for years, 
without the general health suffering in any way. 

The ideal treatment of spinal disease, then, is absolute fixation 
of the spine in the recumbent posture, with the use of extension 
to the head and feet, and, if the patient will submit to it and it 
can be carried out, this treatment should be continued for at 
least six months. By that time, if things have gone on well, 
it will become a question of allowing the patient greater free- 
dom. This question arises especially in adults, and depends 



348 DISEASE OF THE SPINAL COLUMN. 

very much on the seat of the disease. As regards the various 
forms of spinal apparatus, I may say at once that as a curative 
means they are of use chiefly in adults, and in lumbar or dorso- 
lumbar and cervical disease In children, and in mid or upper 
dorsal disease, they are for the most part inefficient, because in 
children the pelvis is not developed sufficiently to form a proper 



Fig. 54. — Phelps's box for spinal disease. 

basis of support, and in upper dorsal disease, unless combined 
with a cervical collar holding up the head, but little support is 
given, and even then there is no proper fixation of the spine. 
All arrangements for holding up the head by means of a jury 
mast are very imperfect. 



PHELPS'S BOX. 349 

In children, either from the first, or, better, after a preliminary 
period of absolute recumbency in bed with double extension, 
Phelps's box is the best apparatus to employ. Phelps's box is 
a trough of wood, in which the body of the patient lies, having 
two narrower troughs diverging from each other for the lower 
extremities. The box is made somewhat broader than the 
patient, so as to allow for lateral pads, which fix him while he 
rests on a mattress or pads so arranged as to prevent undue 
pressure on the curve. Opposite the buttocks the wood is 
hollowed out so as to permit defsecation. The sides of the 
trough are about 6 inches high for the trunk and lower for the 
legs; they are hollowed out opposite the shoulders so as to 
allow free play for the arms. At the feet there are vertical 
pieces of wood, to which the feet are bandaged, a pad, of course, 
intervening. It is well to continue the splints about 18 inches 
above the head, so as to allow room for elastic extension 
attached to bands under the chin and occiput, and to buckles at 
the top of the splint. The patient is carefully wedged in with 
pads and bandaged to the splint (Fig. 54). In this apparatus 
the child lies at absolute rest, and is easily carried about. 
Further, if the head extension is applied and the lateral pads 
carefully wedged in, the box may be tilted up so that the 
patient may look out of the window, &c. Defsecation and 
micturition are performed without disturbing the patient. By 
undoing the bandages the front and sides and limbs of the child 
are easily washed without any disturbance, and when it is 
necessary to wash the back the apparatus is turned upside down 
on a bed, and then lifted off the child ; the patient is replaced 
in the reverse manner and not by lifting him into the box. 
Children should be kept in this apparatus for at least two or 
three years. The whole apparatus with mattresses costs from 
15s. to 20s. (Fig. 55). 

In private practice these boxes can be made more elegant by 
having the sides of strong wicker work, the bottom remaining 
wood. 



350 



DISEASE OF THE SPINAL COLUMN. 



An apparatus in some ways more convenient but by no 
means so efficient is a double Thomas's splint, provided with a 
head rest, the interval between the two upright bars from the 
buttocks upwards being filled up by a piece of strong canvas. 

When the child is ultimately better a light poroplastic jacket 




Fig. 55.— Child fixed in Phelps's box. 

worn for a few weeks gives him a feeling of ''security, and 
prevents too sudden use of the spine, and is, therefore, of some 
advantage at this period, but at an earlier stage, as a support 
for the spine in children, it is not only useless, but in many 
cases positively harmful. The reason for this is that the pelvis 



TAYLOR'S BRACE. 351 

is imperfectly developed, and therefore there is no part for the 
pelvic band to get a proper purchase against. 

In adults, when the disease is in the lumbar or dorso-lumbar, 
or in the cervical regions, it may be treated from the first with 
suitable spinal supports, but it is much better if the patient can 
manage it to employ absolute recumbency with double extension, 
in the first instance for three to six months. It is not, how- 
ever, necessary with the disease in this situation to confine the 
patient to bed for a longer period. In a few months, under the 
action of perfect recumbency with extension, the new inflam- 
matory material will have become organised and to some extent 
ossified, and in the adult the pelvis is broad and forms a fairly 
efficient basis of support. Where the disease is in the lumbar 
or dorso-lumbar regions, and is not extensive, Sayre's plaster 
of Paris jacket, put on while the patient is suspended, 
acts very well, or in cases where a removable apparatus is 
desired, a poroplastic jacket may prove a fairly efficient 
substitute. 

The idea that these corsets will act by lifting up the thorax 
from the support on the pelvis is an erroneous one, they really 
act by preventing the upper part of the spine from falling 
forwards, and this is much more efficiently carried out by the 
' forms of apparatus spoken of by the Americans as Braces, of 
which Taylor's brace is one of the best. It must be remembered 
that the articular processes, lamina;, spines and their ligaments, 
all remain intact although the bodies of the vertebrae are 
destroyed, that the upper part of the spine merely falls 
forward and does not bodily descend, and that the object is not 
to push up the upper part of the trunk as a whole, but to keep 
back the upper part of the spine and prevent it rotating 
forwards on the pivot formed by the articular processes, &c, 
and thus crushing the softened bodies together. The principle 
of the brace is to place a bar on each side of the spine, having 
their fixed points at the pelvis and their fulcrum at the seat of 
disease, and then by an apron over the front of the thorax pull 



352 



DISEASE OF THE SPINAL COLUMN. 



back the upper part of the spine, or at any rate prevent it from 
falling forwards (Fig. 56). 

I may quote the description of Taylor's brace from Bradford 
& Lovett's " Orthopaedic Surgery." " In the first place, a tracing 
of the back is made. This is done as follows : — The patient lies 
upon a hard surface, and a strip of flexible metal (lead, or a 
mixture of lead and zinc) strong enough to retain its position 




Fig. 56. — Taylor's brace applied. (After Bradford and Lovett.) 

and pliable enough to be readily bent is laid upon the back, 
from the neck to the sacrum, so as to accurately fit the lines of 
curve presented by the spinal column. The lead is removed, 
laid on its side upon a piece of stiff cardboard, and the inner 
outline traced. . . . The simplest antero-posterior apparatus 
consists of two uprights of annealed steel, three-eighths or one 
half of an inch in width, and thick enough to be rigid. The 



TAYLOR'S BRACE. 



353 



gauge numbers of the steel as to thickness should be eight to 
twelve. These uprights should reach from just above the 
posterior superior iliac spines to about the level of the second 
dorsal vertebra. The uprights are joined together below by an 
inverted (J -shaped piece of steel, which runs as far down on the 
buttock as possible without reaching the chair or bench where 
the patient sits down. . . . The uprights are joined above by 
another U- sna ped piece, the upper ends of which should pass 

over to the anterior aspect of the 
elevation of the shoulders, or rather 
to the root of the neck. 

" The uprights should be far 
enough apart to support the trans- 
verse processes of the vertebras and 
not the spinous processes. They 
should be bent according to a card- 
board tracing of the back, taken as 
described, and then adjusted to the 
back. The neck and bottom pieces 
should be cut out in cardboard in 
pattern. The whole should then be 
riveted together and tried on the 
patient, who should be lying on his 
face in the recumbent position. 
Any alteration necessary in the 
curves of the steel in order to have 
the appliance fit closely to the back 
along its whole length can be made with wrenches. The brace 
can then be wound with strips of Canton flannel, faced with 
hard rubber and covered with chamois, or be covered smoothly 
with leather. An accurate fit is essential, the covering is 
merely a matter of detail. 

"Pad-plates covered with felt or hard rubber are needed. 
In some instances, at the points of greatest pressure (the fulcrum 
of the lever, &c), the bars of the brace, if well padded, answer 
23 




Fig. 57. — Taylor's brace. 
(After Bradford and Lovett.) 



354 DISEASE OF THE SPINAL COLUMN. 

every purpose. Buckles are needed ao the ends of the neck 
piece, at a level with the axilla, opposite the middle of the 
abdomen, and at the lower end of the brace. . . . (Fig. 57). 

'' It is, of course, essential that the trunk be properly secured 
to the brace. This can be done by means of an apron which 
covers the front of the trunk, the abdomen, and the chest, 
reaching from the clavicles nearly to the. symphysis pubis. The 
apron is provided with webbing (non-elastic) straps, which are 
fastened into buckles attached to the brace. Padded straps 
passing from the top of the brace, around the arms, under the 
axillae, and attached to buckles in the middle of the brace help 
to secure it ; but the scapula;, being movable, cannot be relied 



Fig. 58. — Apron for Taylor's brace. (After Bradford and Lovett.) 

upon alone to fix the trunk, and the apron must be furnished 
with straps at the top which pass over the shoulders to 
buckles in the top of the brace (Fig. 58). 

"In adults, it is often convenient to have the apron split 
down the front and provided with webbing straps and buckles 
It can then be adjusted by the patient himself without touch- 
ing the straps at the back, which secure the apron to the brace. 

"A useful addition in certain cases of dorsal caries is found 
in the use of Dr. Taylor's chest piece. By means of hard 
rubber pads a definite counter point of pressure is furnished at 
the upper part of the chest which keeps the brace closely 
against the back. The pads of the chest piece may be made of 



TAYLOR'S BRACE. 



355 



hard rubber and fit in below the clavicles where they cause no 
discomfort, and restrict the chest movements less than the 
apron, besides affording more definite support (Fig. 59). 




Fig. 59. — Taylor's chest piece. (After Bradford and Lovett.) 

" The brace should be worn day and night, and removed 
daily that the back may be bathed. While the brace is off the 
patient should lie on the face or the back. On no account 
should he sit erect. The back after being washed should be 
rubbed with alcohol and then powdered with face powder, corn 
starch, or Pears' fuller's earth. The brace should then be 
applied and buckled tightly into place. 

" Chafing of the back is sometimes unavoidable in summer. 





Pig. 60. — Cuirass for cervical or upper dorsal disease. (After 
Bradford and Lovett.) 

When a severe chafed spot forms, the brace must be removed 
for the time, and the child lie flat in bed until the ulcer heals." 
Where the disease affects the cervical region the best forms 



356 



DISEASE OF THE SPINAL COLUMN. 



of apparatus are those in the form of a collar which have a 
support on the shoulders, and grasp the head so as to fix and 
support it. There is a number of these collarettes which act 
very well, but a very simple one is made of poroplastic. I 
believe that here also the essential basis of support should be 
the pelvis, and that from a pelvic band a poroplastic jacket 
should extend upwards grasping the thorax, covering the 
shoulders, and expanding at the upper part to receive the 
head (Fig. 60). By having a hold of the pelvis flexion of the 




Pig. 61. — Another form of neck support. 
(After Bradford and Lovett.) 

cervical spine is prevented, which is not the case where the 
apparatus rests on the shoulders or even extends lower down 
and is fixed round the thorax. To Taylor's brace a steel ring 
can be attached by an upright rod, the ring being made to open 
in front, and so arranged as to act as a rest for the chin, and 
occiput counter pressure being arranged at the upper part of 
the dorsal region {see Figs. 61 and 62). There is a great number 



DOUBLE EXTENSION IN PARALYSIS. 



357 



of supports of this kind for cervical disease, which need not, 
however, be detailed here (Fig. 63). 

Where paralysis is present double extension acts in many 
cases like a charm. I have in quite a number of cases now 
employed this method, in more than one of which I felt almost 
certain that laminectomy would be necessary, but in all recovery 




Mfc*. 



Fig. 62. — Taylor's brace with head support. (After 
Bkadford and Lovbtt.) 

has begun immediately on employing double extension, and 
really more quickly than in the recorded cases of laminectomy. 
T have already recorded several cases in the British Medical 
Journal for 1892 (see also p. 147), and since then I have had 
several similar cases. On an average, improvement is noticed 



358 DISEASE OF THE SPINAL COLUMN. 

within three days, and goes on steadily till such recovery as is 
possible has taken place, in some cases complete. During the 
progress of the case the limbs should be assiduously massaged 
and the faradic current applied. 

The action of the double extension is not to open out the 
curved spine, but to bring about the cessation of the pachymenin- 
gitis evidently kept up by the muscular contraction. There is 
no more striking proof of the great value of double extension 
in progressing spinal disease than this rapid disappearance of 




Fig. 63. — Ring support for head. (After Bradford and Lovett. ) 

paralysis under its employment. I think this method should 
always be used for two or three weeks before proceeding to the 
operation of laminectomy, and, judging from my own experience, 
the latter operation will be very rarely required. Certain 
cases, however, remain, in which laminectomy is the only treat- 
ment which promises relief, such cases as abscess in the spinal 
canal, the presence of a mass of caseous material, or constriction 
of the cord from thickening of the dura mater all round it. 



TREATMENT OF SPINAL ABSCESS. 359 

The following is the best method of performing laminectomy : 
— An incision is made in the middle line down to the spines of 
the vertebrae to be operated on, and by means of a periosteum 
detacher the muscles and periosteum are peeled off on each 
side so as to expose the lamina;. The spine or spines are then 
clipped off with curved bone forceps, and by means of a saw the 
laminae are nearly sawn through, the division being completed 
by bone forceps ; the ligaments being then divided at the lower 
part, the plate of lamina? and ligaments can be turned up 
like the lid of a box, and either removed at once, or left 
attached and replaced after the completion of the operation. 
The cord is then exposed, covered by the dura mater, and the 
soft tissue in front clipped or curetted away ; if the whole dura 
mater is thickened it can be slit open, and room be obtained in 
this way for the cord. Of course, spicules of bone can also be 
removed, or pus evacuated if necessary. As I have already 
said, this operation is really much more rarely required than 
one would think from the frequency with which it is done by 
those who advocate it. 

Lastly, we have to consider the treatment where abscesses 
have formed in connection with spinal disease. I have already 
(p. 176 et seq.) described the treatment of chronic abscess gener- 
ally, and in the case of spinal disease we are usually limited to the 
plan of scraping and washing out the abscess, injecting iodoform 
and glycerine, and stitching it up. It is only in abscess con- 
nected with posterior disease, especially of the spines, or in some 
rare cases of cervical abscess, that we can dissect out the wall, 
and deal with the diseased bone. As to the place to open the 
abscess, the rule should be first, a point which gives one the 
freest access to the whole cavity, and secondly, one as far 
removed as possible from sources of contamination, so that 
should union by first intention fail, one has plenty of room for 
the overlapping of the dressings. 

In the case of retro-pharyngeal abscess, the best situation for 
the incision is behind the stemo-mastoid at the upper part ; the 



360 DISEASE OF THE SPINAL COLUMN. 

abscess should never be opened from the throat. An incision 
is made parallel to the posterior border of the sterno-mastoid 
muscle at the upper part, above the point of exit of the spinal 
accessory nerve ; after dividing the deep fascia the muscle is 
lifted up, and the finger or blunt instruments are gradually 
insinuated in front of and close to the spine, and behind the 
large vessels, till the abscess cavity is reached. A sharp spoon 
is then introduced and the sac thoroughly cleared out, care 
being taken not to perforate the anterior wall with the instru- 
ment. Iodoform and glycerine is then injected, and the wound 
stitched up. If the cavity fills up again to a marked degree, 
or if healing does not occur, it is easy to open up the canal and 
put in a tube, and, if the hair is shaved away for some distance 
around, good overlapping of the antiseptic dressings is provided 
for. Where the disease is lower down in the cervical region 
and the abscess is in the posterior triangle, the greater part of 
the wall can usually be more thoroughly removed, and the 
affected bone can be scraped or gouged away. In clearing out 
dorsal or lumbar abscesses, the narrow channel through which 
the pus has passed backwards should be thoroughly opened up, 
and the whole cavity cleared out. In the case of psoas abscess, 
the best incision in the first instance is just internal to the 
anterior superior spine, and if necessary a second incision can 
be made further back above the crest of the ilium, in order to 
get better access to the bone in cases of disease of the lumbar 
vertebra?, but one cannot in reality deal satisfactorily with the 
bone disease in this region. It is in the first place too far away, 
and in the second place too extensive, and not sufficiently 
limited to one side to allow one to get at it properly. Sequestra 
may, however, be got away by the upper incision. 

Disease of the Sacroiliac Synchondrosis. 

This disease may be primary or secondary to disease of the 
lower lumbar vertebrae, in either case it is very often combined 



SACRO-ILIAC DISEASE. 361 

with lumbo-sacral disease. Where it is secondary to lumbar 
disease it most usually begins from the surface in the form of 
a periostitis. When it begins primarily in connection with 
this joint, it generally commences as a deposit in the sacrum or 
ilium, most usually the sacrum, and as these deposits enlarge 
they gradually invade the articulation. The interosseous 
ligament is usually only partially destroyed or may remain 
intact. 

The first symptom of the disease is pain, especially in the 
lumbar region, which is of course worse after exertion ; there 
is often also pain in the buttock, or along the course of the 
sciatic nerve. There is generally a little pufhness to be 
noticed behind, and the muscles of the buttock waste. The 
patient limps, the limb appearing longer because the pelvis is 
tilted downwards on the affected side. Pain may be elicited 
by pressure over the joint behind, or by grasping the anterior 
superior iliac spines, and pressing them together. As time 
goes on the pain and difficulty of movement increase, the leg 
often becomes swollen from pressure on the vein, and abscesses 
form in various situations either in front of or behind the 
joint. If behind the joint they point there, but most usually 
they form in front, and may then burrow in various directions 
according to circumstances, as upwards pointing above the crest 
of the ilium, backwards through the sacro-sciatic notch either 
into the buttock or under the gluteus maximus into the thigh, 
downwards through the obturator foramen, or into the perineum, 
or outwards into the iliac fossa, or along the sheath of the 
psoas into the thigh. 

The prognosis is grave, because phthisis is often present, and 
because of the great difficulty in getting complete fixation of 
the parts. In young subjects, also, where recovery takes place, 
anchylosis results, and oblique deformity of the pelvis is apt 
to result. 

With care the disease can always be diagnosed by the 
symptoms and signs I have mentioned, and the absence of signs 



362 DISEASE OF THE SPINAL COLUMN. 

of disease elsewhere. I need only enumerate the diseases which 
have to be borne in mind — hip-joint disease, spinal disease, 
various neuralgias, disease of the ilium or sacrum at some 
distance from the joint (here movements do not cause pain), 
malignant disease, sciatica (here no pain at articulation, and no 
apparent lengthening of the limb), and from arthritis of the 
synchondrosis after gonorrhoea or puerperal fever (in the latter 
acute suppuration occurs, in the former the disease is acute and 
suppuration is improbable). 

As to treatment, the first essential is rest in the recumbent 
posture between sandbags, or better, in some arrangement like 
Phelps's box, even in adults. No forms of apparatus to allow 
the patient to get about are satisfactory. The actual cautery 
applied behind the articulation before suppuration has taken 
place, is sometimes of use. Where operative interference is 
desirable the joint may be got at from behind, and portions of 
bone chiselled away till the disease is reached, or where the 
disease is anterior the sciatic notch may be enlarged by the 
chisel so as to give free access. Naturally, all the other 
hygienic conditions should be employed in this disease as in 
that elsewhere. 



INDEX. 



INDEX. 










PAGE 






PACE 


Abscess, Chronic, Etiology of, 


74 


Anchyl 


osii- 


of Knee 


-joint, Treat- 


„ „ in connection with 




ment of, 




282 


Joints, Influence 




Ankle 


and Tarsus, 


Treatment of 


on Treatment, 


178 




Disease of, 


302 


., ,. Influence of, on 








Joint, Arthrectomy of, 295 


Operation, 


174 


* 






, Excision of, . . 297 


,, „ Iodoform Emul- 










, Disease of, . 286 


sion in, . 


177 








, ,, 


Amputation in, 297 


,, „ Pathology of, 


70 


] 






, „ 


Frequency of, 286 


„ ,, Removal by Dis- 










' V 


Operation in, 294 


section, . 


176 








, „ 


Pathology of, 286 


,, „ Results of Drain- 










, ,, 


Symptoms of, 288 


age of, 


174 








, ,, 


Treatment of, 293 


,, ,, Treatment of 


175 


Antiseptic 


s, Injection 


of into Tuber- 


Wall of, . 


72 


cular Jo 


ints, 


165 


,, „ in connection with 




Arthrectomy, Complete, Danger of, 190 


Knee-joint Dis- 




„ 




,, 


Description 


ease, 


256 








of, . 187 


,, ,, „ Treatment of, 


279 


,, 




)> 


Definition of, 187 


,, „ „ Hip-joint Dis- 




,, 




,, 


Growth of 


ease, 


228 








Limb after, 192 


„ „ „ Treatment of. 


239 


,, 




,, 


in early Dis- 


Accessory Factors in Production of 










ease, . 182 


Bone and Joint Disease, . 


93 


,, 




,, 


in early Hip- 


Acetabular Disease, 


209 








joint Disease, 230 


Acetabulum, Enlargement of, 


199 


,, 




„ 


in early Knee- 


Actual Cautery, .... 


153 








joint Disease, 269 


Acute Tuberculosis after Operation, 


168 


,, 




„ 


in second stage 


Adduction in Hip-joint Disease, 










of Knee-joint 


Estimation of, . 


211 








Disease, . 275 


Age, in Relation to Expectant Treat- 




,, 




,., 


of Ankle-joinf, 295 


ment, 


170 


,, 




,, 


of the Elbow- 


., „ to Phthisis, . 


113 








joint, . 313 


„ ,, to Severity of Dis- 




,, 




,, 


of Knee, 


ease, 


118 








flexion after, 191 


,, „ to Tubercular 




,. 




utility of Limb after, 191 


Disease of 




,, 




versus Excision, . 190 


Joints, . 


112 


,, 




Partial 


in Knee-joint 


Amputation. Cases suitable for, 


186 








Disease, . 272 


„ in Ankle-joint Disease, 


297 


,, 




,, 


in Wrist-joint 


,, in Hip-joint Disease, 


245 








Disease, . 318 


,, in Knee-joint Disease, 


278 


)> 




,, 


scope of, . 185 


„ in Tarsal Disease, . 


302 


Arthrotom 


f in Tubercular Joint 


,, in Wrist- joint Disease, 


319 






Disease, . . 155 


Anchylosis, Cure by, 


127 


,, 




in Wrist-joint Disease, 318 


„ in Hip-joint Disease, 


220 


,, 




Method of Performance 


„ in Knee-joint Disease, 


256 






of, 


156 


,, of Hip, Treatment of, . 


246 




» 




Results of, . . 158 



366 



INDEX. 



Arthrotomy, Value of, . . . 58, 173 

Astragalo-calcanean Joint, Disease of, 291 

,, scaphoid Joint, Treatment 

of Disease of, . . 300 
Astragalus, Disease of, . 289, 292 

Atlo-Axoid Disease, . . . 340 
Atrophy of Muscles in Hip-joint 

Disease, 201 

Author on the Age for Spinal 

Disease, 330 

Author's Experiments on Induction 
of Bone and Joint Dis- 
ease in Animals, . 85 
,, Explanation of Scarcity 
of Bacilli in Strumous 
Joint Diseases, . . 80 
,, Statistics on relation of 
Tubercular Joint Dis- 
ease to Tuberculosis 
elsewhere, ... 82 

Bacilli, Factors influencing their 

Virulence, . . . 134 
,, in Caries Sicca, . . 64 

„ in the Generative Organs, 97 

in " Healed Tubercle," . 124 
, , in Strumous Joint Diseases, 
Author's Explanation of 
Scarcity of, . . . 80 

, , in Strumous Dactylitis, . 63 

,, in Tubercular Bone and 

Joint Disease, . 78 

,, Injection into Joints and 

Bones, . 88 

,, ,, ,, Nutrient Artery, 86 

,, „ of, causing Joint 

Disease in 
Animals, . 84 

,, Number of, required for 

Infection, . . . 99 

,, Points of Entrance of, . 94 

,, Situation of, in Tubercle, . 11 

Barker's Flushing Spoons, . . 177 

Barner on Accidental Infection 

with Tuberculosis, . . . 78 

Baumgarten on the Epithelioid 

Cells of Tubercle, . . _ . 12 

Benzoate of Soda in Tuberculosis, 163 

Bidder on Food in relation to 

Tuberculosis, .... 121 
Billroth on Phthisis, &c, after 

Operation, .... 83 

Billroth and Menzel on Disease of 

Ribs, . . 322 
„ ,, on relation of 

Tubercular 
Bone Disease 
to Tuberculosis 
elsewhere, . 83 



Billroth and Menzel on Spinal Dis- 
ease, ...... 

Blasius on Pathology of Hip- joint 
Disease, ..... 

Bone, Diffuse Condensation of, 
„ „ Softening of, in Tuber- 

culosis, 
„ Miliary Tuberculosis of, 
„ Quiescent Tubercle in, 
,, Soft Caseating Tubercular 

Deposits in, . 
„ Tubercular Deposits in, 
„ „ Disease of the 

Surface of, 
,, ,, Necrosis of, . 38 

Bonnet's Wire Cuirass for Hip- 
joint Disease, . . . 229, 234 

Bouilly on Bacilli in Strumous 
Diseases, ..... 

Brace, Taylor's, for Spinal Disease, 

Braces in Spinal Disease, 

Brehmer on Food in relation to 
Phthisis, ..... 

Brissaud on Early Symptoms of 
Tubercular Joint Disease, . • . 

Bronchial Glands, Disease of, 



330 

195 
66 



31 
127 

32 
31 

56 



79 
351 
351 

132 

131 

96 



Calcaneo-cuboid Joint, Disease of, 
Calcification of Tubercle, 
Carabelli on Caries Sicca, 
Caries, ...... 

„ Clinical Value of Facts as 

to, . 
,, Sclerosis of Bone in, . 
„ Types of, .... 

„ Sicca, .... 

,, „ in the Knee-joint, 
,, „ „ Shoulder-joint, 
Cartilage, Articular, Changes in, . 
„ ,, Destruction of, 

from beneath, 
„ n Mode of Destruc- 

tion of, from 
the surface, 
Cartilages, Semi-lunar, Disease of, 
Caseation of Tubercle, . 

, , versus Chronic Suppura- 
tion, ...... 

Caseating Tubercular Deposits in 
Bone, bursting into Joints, 
„ „ Further History of, 

>, „ Mode of Formation of, 

„ „ Pathology of, . 

Cautery, Actual, in Hip-joint 
Disease, 
>■ „ in Second Stage 

of Hip-joint 



in Shoulder-joint Disease, 



291 
16 
64 
46 

57 
55 
53 
64 
250 
306 
46 

49 



47 
32 
15 

74 

37 
37 
36 
32 

229 



234 
308 



Celli and Guarneri on Infection by 
Sputum, ..... 
Cervical Abscess, Treatment of, . 
„ Glands, Disease of, . 
„ Spinal Disease, 
., „ „ Apparatus for, 

Cervico-dorsal Spinal Disease, 
Cbaffey, Wayland, on Lymph 
Stasis, ..... 
Changes in the Synovial Mem- 
brane, ..... 
Chauveau on Intestinal Ulceration 
on feeding animals with Tuber- 
cular Material, .... 
Chloride of Zino in Tubercular 
.Joint Disease, .... 
Clavicle, Disease of, 
Climate, Action of, 
,, Choice of, 

„ in relation to Tuberculosis, 
,, in the Treatment of Sur- 
gical Tuberculosis, 
Clinical Significance of the various 
types of Synovial Disease, 
,, Value of Facts as to Caries, 
Coats on the Frequency of Cure in 

Tubercle, 

Conditions favouring Deposit of 
Organisms, .... 

Cornet on Distribution of Tubercle 
Bacilli, ..... 
Corsets in Spinal Disease, Action of, 
Counter Irritation in Knee-joint 
Disease, . 
„ ,, in Tubercular Bone 

and Joint Disease, 
Crossed-leg Deformity, . 

„ ,, Treatment of, 

Cuboid, Treatment of Disease of, . 
Cuneiform Bones, Disease of, 

„ „ Treatment of 

Disease of, . 
Curability of Tuberculosis, . 
Curvature of Spine, Causes of, 
Czerny on Accidental Infection 
with Tuberculosis, 



Dactylitis, Strumous, . . 60, 
Davis-Taylor's Splint for Hip-joint 

Disease, ..... 
Delpech on Tubercle, 
Deposit of Organisms, Conditions 

favouring, .... 

Diet in Tuberculosis, 

Dislocation in Hip-joint Disease, 199, 215 
Dissemination of Tubercle by 

Operation, ..... 
Dorsal Abscess, Treatment of, 

„ Spinal Disease, . 



INDEX. 




367 


PAGE 






PAGE 




Dorso-Lumbar Spinal Disease, 


343 


165 


Dose of 


Bacilli required for In- 




360 


fection 




99 


95 


Drachmann on the Age for Spinal 




340 


Disease, ..... 


330 


356 








341 


Elbow- joint, Arthrectomy of, 


313 






Excision of, 


314 


133 


n 


Disease of, 


310 




>i 


,, Expectant 




19 




Treatment 








in, . 


313 




,, 


,, Frequency of, 


310 


95 


>> 


„ Pathology of, 


310 




> j 


,, Symptoms of, 


311 


164 


S5 


,, Treatment of, 


312 


326 


Empyema Tuberculosum, 


29 


140 


Encapsulation of Tubercle, . 


124 


139 


Epithelioid Cells, .... 


8 


130 


" 


,, Objections to, as 
the Essential 




138 




Elements of 








Tubercle, 


13 


27 


,, 


,, Origin of, . 


13 


57 


,, 


,, Relation of Bacilli 








to, . 


11 


126 


,, 


„ Significance of, in 








Tubercle, . 


11 


100 


Erasmus 


on Pathology of Ankle- 






joint Disease, 


286 


129 


Excision 


Danger of, 


190 


351 


i» 


Early, of Hip, 


235 






in Wrist-joint Disease, . 


319 


268 


,, 


Intra-Epiphysial, of Knee- 








joint, .... 


274 


152 


,, 


Method of Performance of, 


189 


221 


,, 


of Ankle-joint, 


297 


247 


,, 


of Elbow-joint, 


314 


300 


„ 


,, Functional 




291 




Results of, 


315 






of Hip, Imperfect Functional 


300 




Result after, . 


237 


122 




„ in Second Stage, 




145 




Cases where 








necessary, 


239 


76 




Methods, . 


243 






„ in Third Stage, . 


241 


1, 321 


,, 


„ Objections to, 


237 






„ Shortening after, 


237 


234 




of Knee, Flexion after, . 


191 


3 


„ 


,, joint, Advantages 








of, 


275 


100 




„ „ Method of, 


276 


142 




of Os Calcis, . 


299 


9,215 




Shortening after, 


192 




,, 


of Shoulder-joint, 


SOS 


168 


„ 


of the Wrist-joint, . 


319 


360 




in the Treatment of Tuber- 




343 




culosis, 


141 



368 



INDEX. 



PAGE 

Expectant Treatment, . . . 142 
,, „ Cases suitable 

for, . 167,171 
Extension, Cases suitable for, . 144 
,, in Ankle-joint Disease, 294 
„ in Hip-joint Disease, . 227 
„ in Joint Disease, . . 144 
,, in Knee-joint Disease, . 268 
„ in Second Stage of Hip- 
joint Disease, . . 232 
,, in Spinal Disease, . 346 
„ „ „ with 

Paralysis, . 145, 357 

Object of, ... 144 



Eace, Disease of Bones of, 
Eactors, Accessory, in Production 

of Bone and Joint Disease, 
Femur, Disease of Neck of, . 

„ Shortening of Neck of, 
Eevers in Relation to Tuberculosis, 
Fibro Cartilage, Tubercular Disease 

of, 

Fibroid Induration of Tubercle, . 
Finger, Disease of, ... 
Food in Relation to the Production 

of Tuberculosis, 
Fowler on the Frequency of Cure 

in Tubercle 

Frequency with which different 
Bones and Joints 
are attached, . 
„ of Disease in various 

Joints in relation 
to Age, 



329 

93 
209 

215 
132 

52 
124 
321 

120 

126 



106 



115 



246 



Gant on Anchylosis of Hip, . 
Garre on the Etiology of Chronic 

Abscess 75 

Gerhardt's Experiments on the 

Number of Bacilli required for 

Infection 100 

Gelatinous Infiltration, . . 22 

Giant Cells in Tubercle, . . 8 

„ „ Origin of, . . . 14 

Goats, Experiments on, . . 86 

Gommes Scrofuleuses, Treatment of, 176 
Gooeh's Splint for Knee-joint Disease, 264 
Gutenberg on Tubercle Bacilli in 

Caries Sicca, . 64 



Haberern on Pathology of Hip- 
joint Disease, . . 195 
„ on Pelvic Abscesses in 

Hip-joint Disease, . 219 
Harris on the Frequency of Cure 
in Tubercle 126 



Heitler on the Frequency of Cure 




in Tubercle, .... 


126 


Heredity 


of Tuberculosis, 


96 


,, 


„ Meaning of, 


128 


„ 


Tubercular Disease, . 


120 


Hip-joint 


Modes of Excision of, . 


243 


,, 


Abscess, Treatment of, 


239 


>) 


Disease, 


195 




„ Abscesses in 






connection 






with, . 200, 218 


,, 


,, Actual Cautery 






in, . 154, 22!) 


„ 


„ Actual Cautery 






in Second 






Stage, 


234 


„ 


„ Amputation in, 


245 


H 


„ Anchylosis in, . 


220 


,, 


,, Atrophy of 






Muscles in, . 


201 


>> 


„ Bonnet's Wire 






Cuirass, 


229 


11 


„ Causes of Death 






in, 


222 


„ 


,, Causes of Shor- 






tening in, 


213 


„ 


„ Changes in Bone, 






Causes of, 


198 


,, 


,, Crossed-leg De- 






formity in, . 


221 


„ 


„ Diagnosis of 






Primary Seat, 


208 


„ 


,, Diagnosis of 






First Stage, . 


204 


„ 


„ Diagnosis of 






Second Stage, 


217 


t> 


„ Diagnosis of 






Third Stage, . 


219 


,, 


„ Dislocation in, 199 


,215 


,, 


„ Early Arthrec- 






tomy in. 


230 


') 


,, Estimation of 






Adduction, . 


211 


„ 


,, Estimation of 






Flexion, 


211 


t) 


„ Estimation of 






Shortening in, 


214 


n 


„ Excision in 






Third Stage, . 


241 


1> 


,, Excision during 






Second Stage, 


235 


»> 


„ Expectant Treat- 






ment, . 


224 


)) 


„ Extension in, . 


227 


„ 


„ Extension in 






Second Stage, 


232 


5) 


„ Frequency of, . 


195 


,, 


General Treat- 






ment of, 


247 



INDEX. 



369 



Hip-joint Disease, Method of Exa- 
mination of 
Patient, 

.. ,. Objection to 

Excision in, . 

n „ Pain in, . 

,. ., Pathology of, 

„ .. Pelvic Abscesses 



in, 
Phelps's 



Box 



„ ,, Prognosis of, 

,, „ Rigidity of 

Joint in, 
,, „ Shortening after, 

,, ,, Stages of, 

,. ,, Symptoms of 

Eirst Stage, 
,, „ Symptoms of 

Second Stage, 
,, „ Symptoms of 

Third Stage, . 
,, „ Symptoms of 

Fourth Stage, 
„ „ Thomas's Splint 

in, 
„ „ Thomas's Splint 

in Second 
Stage, 
„ „ "Traction" 

Splints in, 
,, ,, Treatment of, . 

,, „ Treatment of 

Anchylosis of, 
„ „ Treatment of 

Eirst Stage, 
,, ,, Treatment of 

Second Stage, 
„ „ Treatment of 

Third Stage, . 
„ ,, Treatment of 

Fourth Stage, 
,, ,, Treatment of 

Sinuses, 
„ ,, Variations in 

the. Symptoms, 
Howse on Amputation in Hip-joint 



Hygiene in relation to the Produc- 
tion of Tuberculosis, . 
Hydrops Tuberculosus, 

Incisions in Tubercular Disease, . 
Infection from Genital Mucous 
Membrane, 

„ from Intestine, 

„ from Respiratory Tract, 

„ from Throat, 

„ in Family Life, 

24 



202 

237 
216 

195 

219 

229 

221 

216 
223 
200 

200 

210 

218 

220 

224 

233 

234 
224 

246 

224 

231 

239 
246 
242 

207 

245 

120 
29 

155 

96 
95 
96 
95 
129 



PAGE 

Infection of Animals with Morbid 

Products from Joints, 84 

of Foetus from Mother, 98 

,, with Tuberculosis, . 76 

Infective Nature of Tubercle, . 16 

Inflammation caused by Tubercle, 17 

,, Chronic, in relation 

to Tuberculosis, . 133 
Injury aggravates an existing 

Lesion, . . 133 

,, as a Causal Agent in Joint 

Disease, . . . 104 

„ as Cause of Recrudescence 

of Tuberculosis, . . 102 
as a Factor in the Produc- 
tion of Tuberculosis, . 101 
produces a graver form of 

Disease, . . . 105 

Intestine, Entrance of Bacilli from, 95 
Intra-epiphysial Excision of Knee- 
joint, . . 274 
Iodoform Emulsion in Chronic 

Abscess, . . . 177 
., Injections in Knee-joint 

Disease, . . . 272 
„ in Tuberculosis, . . 166 

,, Packing in Septic Sinuses, 181 

Jaffe on the Age for Spinal Disease, 330 
Jani on Bacilli in the Generative 

Organs, . . 97 

Jaws, Disease of the, . . . 329 

Joint Infection from Bone Deposits, 37 
,, and Bone Disease induced in 

Animals, . 84 
,, Disease, Extension in, . . 144 
,, ,, Muscular Contrac- 
tion in, . 143 
„ „ Strumous, Tubercu- 
lar Nature of, . 76 

Kanzler on Bacilli in Strumous 

Diseases, . ... 79 

Kastner on Production of Tubercu- 
losis by Muscle Juice, . . 101 
Klebs on Absence of Lesion at point 

of Entrance of Bacilli, 95 

Knee-joint, Complete Arthrectomy 

of, . . . 187 

„ Diffuse Synovial Dis- 

ease of, . . . 252 
„ Excision of, . . 276 

,, Localised Synovial Dis- 

ease of, . . . 251 
„ Primary Bone Disease, 257 

„ Treatment of Anchy- 

losis, ... 282 



Disease, 



32, 33, 248 



370 



INDEX. 



Knee-joint Disease, Amputation 

for, . 278,280 

„ ,, Anchylosis in, 256 

., „ Arthrectomy in 

Early Stage, 

„ „ Arthrotomy in, 

,, ,, Counter Irrita- 

tion in, 

., ,, Diagnosis of, 

„ „ Expectant Treat 

ment in, 

„ „ Extension in, 

,, ,, Frequency of, 

„ „ Iodoform Injec- 

tion in, 

„ ,, Operation in 

Second Stage 
of, . . 

„ „ Partial Arth- 

rectomy in, 

„ „ Pathology of, 

,, „ Pressure in, . 

„ „ Question of 

Exercise in, 

„ ,. Sudden Onset 

of Symptoms, 

„ „ Suppuration in, 

„ „ Symptoms of, 

„ „ Symptoms of 

First Stage, 

„ „ Symptoms of 

Second Stage, 

,, „ Symptoms of 

Third Stage, 

,, „ Symptoms of 

Fourth Stage, 

„ „ Treatment of, 

„ ., Treatment of 

Abscesses, . 

„ „ Treatment of 

Bone Deposits, 

,, ,, Treatment of 

Early Stage, 

,, „ Treatment of 

Sinuses, 

„ „ Treatment of 

Third Stage, 

„ ,, Willemer on 

Tuberculosis 
after, . 83 

Koch on Bacilli in Strumous Diseases, 79 
Kocher on Disease of Semi-lunar 

Cartilages, . . . .52, 250 

Kolischer on Injection of Phosphate 
of Calcium, .... 
Konig on Acute Tuberculosis after 
Operation, 
„ on Caries Sicca in the Knee- 
joint, 



269 
156 

26S 
260 

264 

26S 
248 

273 



274 

272 
248 
268 

267 

259 
256 
250 

252 

254 

255 

.256 

263 

279 
283 
264 
280 
279 



164 



168 



250 



Konig on Embolism as » cause of 
Bone Disease, . 

„ on the Pathology of Chronic 
Abscess, .... 

„ on the Pathology of Elbow- 
joint Disease, 

„ on the Pathology of Hip- 
joint Disease, 

„ on the Pathology of Knee- 
joint Disease, 

„ on Polypoid Growths in the 
Synovial Membrane, 

,, on Tubercles in Tubercular 
Bone and Joint Disease, 

„ on Tubercular Meningitis 
in Septic Cases, 

„ on Tubercular Sequestra, . 

,, on Tuberculosis in connec- 
tion with Joint Disease, . 

„ on Tuberculous Hydrops 
and empyema of Joints, . 
Krister on Tubercle, 
Krause, Experiments on Animals, 

,, on the Treatment of Septic 
Sinuses, .... 

,, and Schuchardt on Bacilli 
in Tuberculosis, 



PAGE 

100 
73 
310 
195 
249 
28 



111 

44 

83 

27 

5 

92 

181 

79 



Laminectomy in Spinal Disease 

with Paralysis, . . 146, 151, 359 

Landouzy and Martin on Infection 

by Semen, .... 
Langhans on Tubercle, ... 5 

Lannelongue on Injection of 

Chloride of Zinc, . 164 
„ on Muscular Contrac- 

tion in Spinal 

146 
320 

320 

170 

28 

212 
360 
343 

97 

110 
Martin and Landouzy on Infection 

by Semen, ... 98 
,, on Retrograde Tubercle, . 124 
Massage in Tubercular Joint Dis- 
ease, 160 

Mastoid Process, Disease of, 328 



Lister's Excision of the Wrist, 
,, Splint for Excision of the 
Wrist, 

Localised Deposits in Relation to 

Operation, 

,, Thickening of Synovial 

Membrane, 

Lovett's Method of Estimating 

Adduction in Hip-joint Disease, 

Lumbar Abscess, Treatment of, 

Lumbo-Sacral Disease, . 

Maffucci, Experiments on Eggs, . 
Marsh's Statistics of Hip-joint 



INDEX. 



371 



sles in relation to Tuberculosis, 
ingitis, Relation to Tubercular 
>int Disease, .... 
iscitis Eungosa, 
zel and Billroth on relation 
Tubercular Bone Disease to 
iberculosis elsewhere, 
enteric G-lands. Disease of, 
sicarpal Bones, Osteomyelitis 

itarsal Bone, First, Disease 

a,tarsus, Disease of, 
, , Treatment of Disease of, 

»xas and Verehere on Tuber- 
lar Meningitis after Operation, 
ulicz on the Treatment of 
ironic Abscess, 

alicz-Wladimiroff Excision of 
irsus and Ankle, 
deldorpf on Accidental Infection 
with Tuberculosis, . 
,, on the Pathology of 

Elbow-joint Disease, 
, , on the Results of Ex- 

cision of Elbow-joint, 
,, on Tuberculosis after 

Operation, 
■tarsal Joints, Disease of, 
iry Tuberculosis of Bone, 
ling on Bacilli in Strumous 
iseases, ..... 
ement aids Extension of Tuber- 
lar Disease, .... 
ler on Bacilli in Strumous 
Joint Diseases, 
on Disease of the Spine, . 
on the Age for Spinal 
Disease, 
ich on Pathology of Ankle- 
joint Disease, 
on Tarsal Disea% . 
Bular Contraction in Joint 



jolitan Laws with regard to 
ithisis, ..... 
■osis of Bone, Tubercular, 
ton on Tubercular Disease of 
me, ..... 

neister on Phthisis, &c, after 
ibercular Bone and Joint 
sease, ..... 
et on Pott's Disease, 
ient Artery, Injection of Bacilli 



ation, as a Cause of Dis- 
semination of Tubercle, 



PAGE 

132 



60 



292 
286 



236 
176 
302 
77 
310 
315 



291 
31 

79 

109 

80 
117 

330 

286 

2S7 

143 



137 
38 



83 
3 



168 



Operation, Cases where required, 

,, Choice of, . 

,, Circumstances affecting 

Choice of, 
Os Calcis, Disease of , . 

„ Excision of, . 

,, Treatment of Disease of, 
Osteitis, Rarefying, in connection 
with Tubercular Disease of Bone, 
Osteomyelitis, Tubercular, of Phal- 



Ozsena, Scrofulous, 



with Sequestra, 



PAGE 

171 

173 

173 
290 
299 
298 

35 

321 
60 

329 



Pachymeningitis, Causes of, 
, , , , Effects of, 

, , , , Nature of, 

Pain in Hip-joint Disease, 
Paralysis in Spinal Disease, . 

,, „ „ Causes of, 

,, „ ,, Extension 

in, . 
,, ,, „ Treatment 

of, . 
Partial Arthrectomy, 

„ Operations, Advisability of, 
Patella, Disease of, 
Pelvic Abscesses in Hip-joint Dis- 
ease, 
,, ,, Treatment of, 

Periostitis, Tubercular, 

,, ,, Treatment of, 

Pfeiffer on Accidental Infection 

with Tuberculosis, 
Phalanges, Tubercular Osteomyelitis 

in 60,321 

Phelps's Box for Spinal Disease, . 
,, ,, in Hip-joint Disease, 

,, ,, in Second Stage of 

Hip-joint Disease, . 
Phosphate of Calcium in Tubercular 

Joint Disease, .... 
Phthisis after Disease of Ankle and 
Tarsus, 
,, Relation to Tubercular 
Joint Disease, 
Plaster of Paris in Knee-joint 
Disease, 
„ „ Splint in Hip- 

joint Disease, 
Points of Entrance of Tubercle 
Bacilli, ..... 
Polypoid Growths on Synovial 

Membrane, 
Pressure in Tubercular Joint Dis 

ease, ..... 
Primary Synovial Disease, . 
Psoas Abscess, Treatment of, 
Pus from Chronic Abscess, Nature of, 



145 
145 
145 
216 
339 
151 

145 

357 
184 
184 



219 

241 

58 

158 

77 



349 

229 



233 



164 



292 



82 



265 

234 

94 

28 

160 
26 

360 
71 



372 



INDEX. 



Pyogenic Organisms in relation to 

Tubercle 

Bacilli, . 

„ ,, Relation to 

Tuberculosis, 

Quiescent Tubercle in Bone, 



Rabbits, Experiments on, 
Rarefying Osteitis in connection 

with Tubercular Disease of Bone, 
Red Marrow, 

Renken on Strumous Dactylitis, 
Respiratory Tract, Entrance of 

Bacilli from, 
Rest in the Treatment of Tuber 

culosis, .... 
Reticulum in Tubercle, 
Retrograde Tubercle, . 
Retrogressive Changes in Tubercle. 
Retro- Pharyngeal Abscess, Treat 

ment of, . 
Ribs, Disease of, . 

,, Pathology of, 

„ Symptoms of, 

„ Treatment of, 

„ Tubercular Periostitis of, 
Riedel on Polypoid Growths on the 

Synovial Membrane, 
Rohlff on Infection by Semen, 
Roser on Mikulicz Operation, 



Sacro-iliac Synchondrosis, Disease 
of 

Saxtorph's Bandage, 

Sayre's Plaster of Paris Jacket 
for Spinal Disease, 

Scaphoid, Disease of, 

„ Treatment of Disease of, 

Scapula, Disease of, 

Schede on Rest, .... 

Schlegtendal on Bacilli in Strumous 



Schuchardt and Krause on Bacilli 

in Tuberculosis, 
Schiippel on Tubercle, . 
Sclerosis of Bone in Caries, . 
Scott's Dressing, .... 
,, in Knee-joint Dis- 

ease, 
Scrofulous Ozsena, 
Semen, Infection by, 
Semi-lunar Cartilages, Disease of, 
Sepsis aids spread of Tuberculosis, 
,, in Relation to Acute Tuber- 
culosis, .... 
,, Influence on Treatment, 
Septic Sinuses, Results of, . 
,, Treatment of, 



135 
109 
127 

85 

35 
68 
63 



142 

9 

124 

123 

359 

322 
322 
323 
324 

58 

28 

98 

303 



360 
160 

351 
291 
301 
326 
142 



79 

79 

5 

55 

160 

268 

329 

98 

52 

109 

180 
179 
180 
181 



97, 



Sequestra, Tubercular, ... 39 

„ Konig on, . 44 

Sex in Relation to Disease, . . 119 
Shortening in Hip-joint Disease, 

Causes of. 213 
, „ ,, Estimation 

of, . 214 

Shoulder-joint, Excision of, . . 308 

., Caries Sicca in, . 64, 306 

„ Disease, . . 304 

,, „ Cautery in, 308 

,, ,, Diagnosis of, 306 

,, ,, Frequency of, 304 

Pathology of, 304 
,, ,, Suppuration 

in, . 306 

„ ,, Symptoms of, 304 

,, Treatment of, 307 
Sinuses in Joint Disease, Treatment 

of, ... 242 

,, Tubercular, Treatment of , 167 

Skull, Disease of Flat Bones of, . 326 
Sormain and Pellicarni on Creasote 

Inhalations, . . . 165 

Spina Ventosa, .... 321 

Spinal Abscess, .... 337 

,, Results of Drain 

age of, 
,, Treatment of, 

,, Curvature, . 
,, ,, Causes of. 



Disease, 



Abscess in, . 

Action of Corsets 

in, . . . 351 

Actual Cautery in, 154 

Apparatus for, . 348 

Causes of Deform- 
ity in, . . 332 

Cervical, Appara- 
tus for, . . 356 

Diagnosis of, . 344 

Deformity in, . 336 

Effects on Cord, . 338 

Extension in, . 346 

Frequency of, . 330 

Ideal Expectant 

Treatment of, . 347 

in Cervical Region, 340 
,, Dorsal 

Region, 341 

in Dorsal Region, 343 

in Dorso-lumbar 

Region, . . 343 

in Lumbo-sacral 

Region, . . 343 

Mattress for, 346 

most frequent Seat 

of, . . 331 



174 
359 
336 
145 
330 
337 



INDEX. 



373 



PAGE 

Spinal Disease, Pain in, . , 339 

Paralysis in, 339 

Pathology of, . 331 

Phelps's Box for, . 349 
Plaster of Paris 

Jacket for, . 351 
Posterior, . . 332 
Prone Couch for, 345 
Recumbency in, . 345 
Rigidity in, . 335 
Symptoms of, 333 
Taylor's Brace for, 351 
Thomas's Splint for, 350 
Treatment of, . 345 
Ab- 
scesses in, 359 

Par- 
alysis in, 357 
with Paralysis, ex- 
tension in, . 145 
,, Paralysis, Laminectomy for, 359 
Spine, Examination of, for Disease, 334 
Spontaneous Cure of Tubercle, . 125 
Sputum, Disinfection of, . . 136 
Steinheil on Production of Tuber- 
culosis by Muscle Juice, . . 101 
Sternum, Disease of, . . . 325 
Strumous Dactylitis, . . 60, 61, 321 
,, Bacilli in, . 63 
Treatment of, 322 
„ Diseases, Tubercles in, . 78 
,, Joint Diseases, Tuber- 
cular Nature of, 18, 76 
Suppuration, Chronic, in relation to 
Expectant 
Treatment, 170 
,, ,, Pathology of , 70 
Syme's Amputation in Ankle-joint 

Disease, ..... 297 
Synovial Disease, Course of. . . 23 
Microscopical Char- 
acters of, . 20 
Primary, . . 26 
Secondary to a 

Bone Deposit, 26 

Third Type of, . 25 

Second Type of, 24 

Varieties of, . 19 

Membrane, Acute Miliary 

Tuberculosis of, 29 
,, Changes in, . 19 
,, Diffuse Thicken- 
ing of. . 19 
,, Localised Thick- 
ening of, . 28 
„ Polypoid Growths 

on, . . 28 
,, Types of Diffuse 

Thickening of, 19 



Tappeiner's Inhalation Experiments, 
Tarsal Disease, Amputation in, 
Tarsus, Disease of, 

,, Frequency of Disease in 

various Bones, 
, , Partial Operations on, 
,, Pathology of, . 
,, Symptoms of Disease of, . 
,, Treatment of Disease of, . 
Taylor's Brace for Spinal Disease, 
„ „ Addition to, for 

Cervical Disease, 
Tendons around Ankle, Disease 

of, 

Thomas on Treatment of Hip-joint 
Disease, ..... 
Thomas's Hip Splint, . 
,, Knee Splint, . 
,, Splint for Ankle-joint 

Disease, 
„ , , for Spinal Disease, 

, , , , in Second Stage of 

Hip-joint Disease, 
Throat, Entrance of Bacilli from, . 
Toes, Disease of , . 
Toledo's Experiments on Pregnant 
Guinea Pigs, .... 
" Traction " Splints in Hip-joint 
Disease, ..... 
Tubercle, an Infective Nodule, 
„ Atrophy of, . 
,, Bacilli in relation to the 

Living Tissues, . 
,, Baumgarten on the Essen- 
tial Elements of, 
,, Calcification of, 
., Caseation of, 
„ Dissemination of, by 

Operation, . 
,, Encapsulation of, . 
„ Essential Elements of, 
,, lr Points for the 

Diagnosis of, 
External Wall of, 
,, Fibroid Induration of, . 
„ Giant Cells in, 
,, Histology of, 
,, Histological Definition 

of, . . 
,, History of, 
„ in Strumous Diseases, 
„ Inflammatory Changes 

set up by, . 
„ Irritating Nature of, 
„ Life History of, 
,, Reticulum in, 
„ Retrogressive Changes in 
,, Spontaneous Cure of, 
„ Vascular Origin of, 



PAGE 

122 
302 

286 

287 
301 
287 
290 

298 
351 

354 

293 

223 
224 
266 

294 
350 

233 
95 

321 



234 
16 
14 

122 

12 
16 

15 



124 
10 

17 

7 

124 




3 

78 

17 

17 

14 

9 

123 

124 

14 



374 



INDEX. 



Tubercular Bone and Joint Disease, 

Treatment of, . . 136 
,, Deposits, Danger of, . 168 

,, ,, in Bone, . 31 

,, Infiltration, . . 10 

,, Joint Disease, Relation 

to Phthisis, 82 
, , „ Relation to 

Tubercular 
Meningitis, 82 
,, Meningitis after Operation, 236 

,, Nature of Strumous Dis- 





ease, 


18 


1J 


Necrosis of Bone, 


38 


)! 


Osteomyelitis, 


58 


') 


Periostitis, . 


58 


'» 


Peritonitis, Treatment of, 


157 


13 


Sequestra, . 


39 


)> 


,, Mode of 






Formation of, 42 


)» 


Sinuses, Treatment of, 


167 


Tuberculin, Dangers of, 


161 


„ 


Treatment by, . 


160 


Tuberculosis, Acute Miliary of 






Synovial Membrane, 


29 


„ 


Curability of, . 


122 


„ 


Definition of, 


17 


,, 


General Treatment of, 


138 


)! 


in relation to Chronic 






Inflammation, 


133 


„ 


Injury as a Factor in 






the Production of, 


101 


» 


Local Treatment of, 


142 


» 


Prophylaxis of, 


136 


Ulceration of Cartilages of Knee- 




joint, 




259 


Unrest, 


Causes of, ... 


143 



Verneuil on Accidental Infection 

with Tuberculosis, ... 76 

Vertebrae, Tubercular Periostitis 

of 59 

Volkmann on Caries Sicca, . . 64 

, , on Tuberculosus Hydrops 

and Empyema of Joints, . . 29 

Wagner on Caries Sicca, . . 64 

,, on Tubercle, ... 5 

Wall of a Tubercle, ... 7 

"Wandering " of Acetabulum, . 199 
Wanke on Tubercle Bacilli in 

Caries Sicca, .... 64 

Wartmann on General Tubercu- 
losis after Excision, . . . 168 
Weber on Diet in Tuberculosis, . 142 
Wiessner on Early Symptoms of 

Tubercular Joint Disease, . . 131 
Willemer on Pathology of Knee- 
joint Disease, . . 248 
,, on Phthisis, &c, after 
Disease of the Knee- 
joint, ... 83 
Wrist-joint, Excision of, 
„ Disease, 
„ „ Amputation 



Arthrotomy 

in, . 
Excision in, . 
Frequency of, 
Partial Ar- 

threctomy 

in, . 
Pathology of, 
Symptoms of, 
Treatment of, 



319 
38, 316 

319 

318 
319 
316 



318 
316 
316 
318 



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